Every finding on record at Envive of Lawrenceburg

Based on interview and record review, the facility failed to follow the physicians' orders related to hold parameters for cardiac medications for 2 of 16 residents reviewed for quality of care. (Residents 37 and 63)Findings include:1. Resident 37's clinical record was reviewed on 02/18/2026 at 2:24 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 11/26/2025, indicated the resident's diagnoses included, but were not limited to, Cancer and Adverse Effects of Antineoplastic (agents, drugs, or therapies that inhibit or prevent the development maturation, or spread of caner/tumor cells) and Immunosuppressive Drugs. The resident's current physician's orders included an open-ended order, with a start date of 12/02/2025, for midodrine (a medication used to treat low blood pressure) 5 mg (milligrams) with meals for hypotension. The medication was to be held if the resident's Systolic Blood Pressure (SBP; the top number) was greater than 120. The December 2025, January 2026, and February 2026 Electronic Medication Administration Records (EMAR) indicated the medication was administered when the resident's SBP was over 120 on the following dates and times: - On 12/04/2025 at 12:00 P.M., the resident's blood pressure was 126/74,- On 12/06/2025 at 12:00 P.M., the resident's blood pressure was 124/78 and at 5:00 P.M., the resident's blood pressure was 126/52,- On 12/07/2025 at 12:00 P.M., the resident's blood pressure was 134/86,- On 12/13/2025 at 12:00 P.M., the resident's blood pressure was 122/86 and at 5:00 P.M., the blood pressure was 128/82,- On 12/14/2025 at 12:00 P.M., the resident's blood pressure was 126/84,- On 12/15/2025 at 5:00 P.M., the resident's blood pressure was 121/82,- On 12/20/2025 at 12:00 P.M., the resident's blood pressure was 121/70,- On 12/21/2025 at 7:00 A.M., the resident's blood pressure was 126/72 and at 12:00 P.M., the resident's blood pressure was 134/74,- On 12/26/2025 at 5:00 P.M., the resident's blood pressure was 125/76,- On 12/27/2025 at 12:00 P.M., the resident's blood pressure was 128/80 and at 5:00 P.M., the resident's blood pressure was 122/72,- On 12/28/2025 at 7:00 A.M., the resident's blood pressure was 129/80,- On 12/31/2025 at 7:00 A.M., the resident's blood pressure was 126/78 and at 12:00 P.M., the blood pressure was 122/78,- On 01/03/2026 at 5:00 P.M., the resident's blood pressure was 128/82,- On 01/04/2026 at 12:00 P.M., the resident's blood pressure was 122/80,- On 01/08/2026 at 7:00 A.M., the resident's blood pressure was 141/79,- On 01/11/2026 at 7:00 A.M., the resident's blood pressure was 126/78,- On 01/16/2026 at 5:00 P.M., the resident's blood pressure was 129/62,- On 01/17/2026 at 12:00 P.M., the resident's blood pressure was 132/81,- On 01/30/2026 at 7:00 A.M., the resident's blood pressure was 131/72,- On 02/03/2026 at 5:00 P.M., the resident's blood pressure was 121/78,- On 02/19/2026 at 7:00 A.M., the resident's blood pressure was 131/79, and - On 02/20/2026 at 7:00 A.M, the resident's blood pressure was 135/71 and at 12:00 P.M., the resident's blood pressure was 138/75. During an interview, on 02/20/2026 at 3:07 P.M., Licensed Practical Nurse (LPN) 6 indicated some residents had hold parameters for their cardiac medications. She would assess the resident's blood pressure before administering the medication. If the resident's blood pressure was too high or too low (based on how the physician wrote the order), she would not administer the medication and she would make a note that indicated why the medication was held in the EMAR. 2. The clinical record for Resident 63 was reviewed on 02/19/2026 at 11:49 A.M. A Quarterly MDS assessment, dated 01/19/2026, indicated the resident was cognitively intact. The resident's diagnosis included but was not limited to, hypertension (high blood pressure). An open-ended physician's order, with a start date of 03/14/2025, indicated the resident was to be given Carvedilol (a hypertensive medication) 12.5 mg, twice a day. The staff were to hold the medication if the resident's heart rate was less than 60. The December 2025, January and February 2026 EMAR indicated the resident had received the medication when their heart rate was less than 60 on the following dates and times: -On 12/10/2025 at 8:00 P.M., when the resident's heart rate was 51,-On 12/11/2025 at 9:00 A.M., when the resident's heart rate was 58, -On 12/17/2025 at 9:00 A.M., there was no heart rate documented for the resident, -On 12/19/2025 at 8:00 P.M., when the resident's heart rate was 59, -On 12/20/2025 at 8:00 P.M., when the resident's heart rate was 59, -On 12/25/2025 at 9:00 A.M., when the resident's heart rate was 58, -On 12/26/2025 at 9:00 A.M., when the resident's heart rate was 58, -On 12/27/2025 at 9:00 A.M., when the resident's heart rate was 58,-On 01/01/2026 at 9:00 A.M., when the resident's heart rate was 45, -On 01/04/2026 at 9:00 A.M., when the resident's heart rate was 51, -On 01/09/2026 at 8:00 P.M., when the resident's heart rate was 59,-On 01/10/2026 at 9:00 A.M., when the resident's heart rate was 51, -On 01/11/2026 at 9:00 A.M., when the resident's heart rate was 51, -On 01/16/2026 at 8:00 P.M., when the resident's heart rate was 51, -On 01/18/2026 at 9:00 A.M., when the resident's heart rate was 52, -On 01/23/2026 at 8:00 P.M., when the resident's heart rate was 51, -On 01/27/2026 at 9:00 A.M., when the resident's heart rate was 59, -On 01/29/2026 at 8:00 P.M., when the resident's heart rate was 55, -On 02/04/2026 at 9:00 A.M., when the resident's heart rate was 58, and -On 02/13/2026 at 9:00 A.M., when the resident's heart rate was 55. During an interview, on 02/20/2026 at 10:13 A.M., Qualified Medication Aide 2 indicated if a resident had hold parameters, she would obtain the resident's vitals prior to administering the medication and if the vitals were outside the parameters the physician ordered then she would not administer the medication. The current facility policy titled, Medication and Treatment Orders, with a revised date of 08/2024, was provided by the Corporate Support Staff (CSS) 5 on 02/20/2026 at 2:32 P.M. The policy indicated, .Orders for medications and treatments will be consistent with principles of safe and effective order writing.Medications shall be administered only upon the written order. 3.1-37(a)

Based on record review and interview, the facility failed to ensure appropriate transfer or discharge documentation was provided for 2 of 3 residents reviewed for transfer or discharge. (Residents 66 and 68)Findings include: 1. The clinical record for Resident 68 was reviewed on 02/19/2026 at 11:00 A.M. A Comprehensive Minimum Data Set (MDS) assessment, accepted on 11/17/2025, indicated the resident admitted to the facility from a short-term hospital stay on 11/03/2025 for care after experiencing a stroke. A Social Services Note, dated 11/21/2025 at 3:49 P.M., indicated the resident was accepted at a different long term care facility. The receiving facility would pick her up on 11/24/2025. The resident's census page in her Electronic Health Record (EHR) indicated she was discharged from the facility on 11/24/2025. During an interview, on 02/20/2026 at 1:34 P.M., Licensed Practical Nurse (LPN) 4 indicated when a resident was discharged from the facility, staff were to complete a discharge summary in the computer that recapped the resident's stay and provided information about the resident's care needs. They would make sure to included information about upcoming appointments and prescriptions they might need. The nurse would call report to the receiving facility and send the discharge summary, a face sheet, medication list, nursing notes, and any other discharge documentation required with the resident to the new facility. During an interview, on 02/20/2026 at 2:46 P.M., the Direct of of Nursing (DON) indicated nursing staff had a bad habit of not making copies of transfer/discharge paperwork when they sent someone out of the facility. The facility could not provide the transfer/discharge paperwork that should have been sent with the resident. 2. The clinical record for Resident 66 was reviewed on 02/19/2026 at 10:42 A.M. A Quarterly MDS assessment, dated 11/13/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, cancer and heart failure. A Progress Note, dated 11/14/2025 at 7:00 P.M., indicated the resident's family member had requested the resident be sent to the emergency room. The resident was sent to the local hospital per the request. A Progress Note, dated 11/14/2025 at 10:00 P.M., indicated the resident was admitted to the hospital. The clinical record lacked documentation the resident was provide a transfer/discharge form. The current facility policy, titled Transfer or Discharge, Facility-initiated, dated 08/2024, was provided by Corporate Support Staff (CSS) 5 on 02/20/2026 at 3:19 P.M. The policy indicated, .When a resident is transferred or discharged from the facility, the following information is documented in the medical record.That an appropriate notice was provided to the resident and/or legal representative. 3.1-12(a)(6)(A)

Based on record review and interview, the facility failed to provide a bed hold for a resident sent to the hospital for 1 of 3 residents reviewed for discharge. (Resident 66)Findings include:The clinical record for Resident 66 was reviewed on 02/19/2026 at 10:42 A.M. A Quarterly MDS assessment, dated 11/13/2025, indicated the resident was cognitively intact. The resident's diagnosis included, but was not limited to, heart failure (a chronic progressive condition where the heart muscle cannot pump enough blood to meet the body's needs for oxygen and nutrients). A Progress Note, dated 11/14/2025 at 7:00 P.M., indicated the resident's family member had requested the resident be sent to the emergency room. The resident was sent to the local hospital per the request. A Progress Note, dated 11/14/2025 at 10:00 P.M., indicated the resident was admitted to the hospital for heart failure.The clinical record lacked the resident receiving a bed hold policy with the discharged . During an interview, on 02/20/2026 1:39 P.M., the Director of Nursing (DON) indicated when a resident went to the hospital they should have been given a bed hold policy. During an interview, on 02/20/2026 at 2:03 P.M., Corporate Support Staff (CSS) 5 indicated the resident's bed hold could not be found and the resident should have had one when they discharged in November in their clinical record. The current facility policy titled, Bed Holds and Returns, with a revision date of 08/2024, was provided by CSS 5 on 02/20/2025 at 2:04 P.M. The policy indicated, .All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence) hospitalization or therapeutic leave). Residents, regardless of payor source, are proved written notice about these policies at least twice:.notice 2: at time of transfer (or, if the transfer was an emergency, within 24 hours).Multiple attempts to provide the resident representative with notice 2 should be documented in cases where staff were unable to reach and notify the representative timely.

Based on interview and record review, the facility failed to follow the physicians' orders related to daily weights for 1 of 1 residents reviewed for Hydration Status. (Resident 52)Finding included:The clinical record for Resident 52 was reviewed on 02/19/2026 at 11:21 A.M. An admission MDS assessment, dated 01/12/2026, indicated the resident was cognitively intact. The resident's diagnosis included but was not limited to, metabolic encephalopathy (brain dysfunction caused by chemical imbalances, systemic illness, or organ failure).A physician's order, dated 01/31/2026 through 02/11/2026, indicated the resident was to be weighed daily in the morning for fluid retention. An open-ended physician's order, with a start date of 02/12/2026, indicated the resident was to be weighed daily for fluid retention. The Vitals Record and February 2026 EMAR lacked documented weights for the resident for the following dates: 02/02/2026 through 02/09/2026; 02/08/2026, 02/12/2026, 02/13/2026, 02/15/2026, 02/16/2026, 02/18/2026, and 02/19/2026. During an interview, on 02/20/2026 at 10:11 A.M., QMA 2 indicated if a resident had an order for a daily weight, then the Certified Nurse Aides would usually get the weight and report to her or the nurse. The weight would then be transcribed in the resident's EMAR. If the resident refused the weight, then it would also be documented in the EMAR. During an interview, on 02/20/2026 at 2:58 P.M., CSS 5 indicated daily weights should be documented in the resident's clinical record. The facility did not have a policy related to daily weights. 3.1-46(a)(1)

Based on observation, interview, and record review, the facility failed to store medications appropriately for 1 of 4 medication carts reviewed and 1 of 3 medication rooms reviewed. (South Medication Cart on the third floor and third floor Medication Room) Findings include: 1. On 02/20/2026 at 9:39 A.M., the South Medication Cart on the third floor was observed with Qualified Medication Aide (QMA) 2 and contained the following: - A small round white pill was lying loose in the bottom of the second drawer along with dust and paper debris,- A small round white pill was lying loose in the bottom of the third drawer along with dust and several pieces of paper debris. During an interview at the time of the observation, QMA 2 indicated she was unaware of what the pills were or who they belonged to. There shouldn't be any loose pills in the medication cart. The current Medication Labeling and Storage policy, dated 8/2024, was provided by Corporate Support Staff (CSS) 5 on 02/20/2026 at 2:04 P.M. The policy indicated, .Medications and biologicals are stored in the packaging, containers, or other dispensing systems in which they arrived .2. The third-floor medication room was observed, on 02/20/2026 at 1:21 P.M., with Licensed Practical Nurse (LPN) 4. The medication refrigerator contained an opened vial of Tuberculin (TB) serum, with no date that indicated when it was opened. The vial was half full. LPN 3 indicated the TB serum should be dated when opened and should be discarded after 30 days. There was no delivery date on the serum bottle. She was unsure when it was last used. The TB serum package insert was provided by the CSS 5 on 02/20/2026 at 2:17 P.M. The manufacturer's insert indicated, .vials in use more than 30 days should be discarded .3.1-25(o)

Based on observation, interview, and record review, the facility failed to follow infection control guidelines related to Enhanced Barrier Precautions (EBP) for 1 of 16 residents reviewed for infection control. (Resident 63)Findings include:During an observation, on 02/19/2026 at 10:58 A.M., Licensed Practical Nurse 3 gathered supplies from a treatment cart and entered Resident 63's room. She sanitized her hands and donned gloves. She then provided wound treatment care to the resident. There was no gown donned prior to or during the wound treatment. There was no indication outside or inside the resident room that they were on EBP. The clinical record for Resident 63 was reviewed on 02/19/2026 at 11:49 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 01/19/2026, indicated the resident was cognitively intact. The resident's diagnoses included but were not limited to, anemia, hypertension, renal insufficiency, diabetes, anxiety, depression, cirrhosis of liver, and liver transplant status. A Wound Nurse Practitioner Report, dated 02/03/2026, indicated the resident had dermatosis to the right buttock buttocks. The wound measured 7 centimeters (cm) X (by) 3.8 cm X 0.3 cm. The wound had a moderate amount of serosanguineous (pale red to pink, thin and watery) drainage. The impairment started on 10/28/2025. A Wound Culture Report, dated 02/05/2026, indicated there was a culture from the resident's right buttocks. The wound had the following bacteria:-Sparse growth of Proteus mirabilis,-Very sparse growth of Enterococcus faecalis, and -Sparse growth of Methicillin Resistant Staphylococcus aureus.A physician's order, dated 02/09/2026 through 02/16/2026, indicated the resident was to take Amoxicillin (an antibiotic) 500-125 milligrams for 7 days for a wound infection. The resident's physician's orders lacked and order for EBP. During an interview, on 02/20/2026 at 10:19 A.M., the Director of Nursing (DON) indicated residents were placed on EBP if they had any drains, catheters, colostomy bags, any non-natural device, and chronic wounds. If resident were in EBP then staff should wear a gown, gloves, and face mask. Resident 63 was not on EBP because the wound was clean and not draining. The resident did have a wound infection recently. The resident had the wound since 10/28/2025.The current facility policy titled, Enhanced Barrier Precautions, dated August 2022, was provided by Corporate Support Staff 5 on 02/20/2026 at 2:04 P.M. The policy indicated, .Enhanced Barrier Precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents.EBPs employ targeted gown and glove use during high contact resident care activities.Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include:.wound care (any skin opening requiring a dressing).3.1-18(b)

Based on record review and interview the facility failed to provide appropriate assistance to prevent an avoidable accident for 1 of 3 residents reviewed for accidents hazards. This deficient practice resulted in the resident acquiring right medial and right posterior orbital fractures. (Resident D) Findings include:The clinical record for Resident D was reviewed on 9/22/2025 at 3:15 P.M. An admission Minimum Data Set (MDS) assessment, dated 9/3/2025, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, heart failure, asthma, and respiratory failure. The Resident required maximal assistance to transferring from lying to sitting and sitting to standing.The At Risk for Falls Care Plan, dated 8/27/25 and revised on 9/8/25, indicated the resident will be free of falls. The interventions included, but were not limited to, dated 8/27/25, anticipate and meet the resident's needs; and, dated 9/6/25, resident's room closer to nurses station for closer monitoring.The Physical Therapy Progress Report, dated 8/23/25, indicated the resident required maximum assistA facility incident report, dated 9/6/25, indicated staff found Resident D lying on the floor near the resident's room doorway. The resident had gotten up unassisted and lost balance, the resident was unsure where she was going or what she was needing. The resident had a laceration to the left side of her forehead.During an interview, on 9/22/2025 at 10:45 A.M., Certified Nursing Assistant (CNA) 3 indicated she was getting Resident D up for breakfast on 9/12/2025 and left the resident sitting on the side of the bed while she walked to the far corner of the room to retrieve the resident's wheelchair. While her back was to the Resident, she heard a loud noise and turned to find the resident lying face first on the ground. The resident hit her head hard and broke her dentures. CNA 3 said sometimes Resident C can hold herself up and sometimes she can't. She was told by other staff that the resident had been declining and to be careful with her. Ever since the resident came back from the hospital after this incident, she has required a mechanical lift for transfer and used a specialized mobility challenges ergonomic wheelchair instead of regular wheelchair.During an interview, on 9/22/2025 at 1:30 P.M., Therapy Staff Member 4 indicated Resident C came from home and was at the facility for therapy. Resident C required maximal verbal direction. For example, if you asked her to stand up, she wouldn't understand what you were asking. She was not following direction. She was dropped from seeing therapy after her last fall on 9/12/2025. The last few times Therapy Staff Member 4 helped Resident C she required maximal assistance. She required maximal assistance with two staff members just to get her out of the chair when she was in therapy doing exercises. Therapy Staff Member 4 indicated she would not have left Resident C sit on the side of her bed alone while she retrieved her wheelchair from across the room. During an interview, on 9/22/2025 at 3:40 P.M., RN 5 indicated she was the nurse who responded to Resident C's fall on 9/12/2025. Upon entering the room Resident C was laying on the floor face first with her hands alongside her body like she did not attempt to catch herself. She had a laceration on the side of her face and bruising was already starting. A Hospital Document, dated 9/12/2025 at 8:47 A.M., showed the findings from the computed tomography (CT) scan indicating the resident had a new right medial orbital blowout fracture with opacification of the adjacent ethmoid sinuses. Additionally, a subtle new acute fracture within the posterior right orbital wall. A hematoma in the right cheek with extensive surrounding inflammation. Also, a laceration with a total repaired wound length of 5 centimeters (cm). The current facility policy, titled Falls and Fall Risk, managing, with a revision date of August 2024, was provided by the Administrator on 9/22/2025 at 4:20 P.M. The policy indicated, .the staff will identify interventions related to the residents' specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .The current facility policy, titled Safe lifting and Movement of Residents, with a revision date of August 2024, was provided by the Administrator on 9/22/2025 at 4:20 P.M. The policy indicated, .In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents .This citation relates to Intake 2616965.3.1-45(a)(1)

Based on observation, interview, and record review the facility failed to provide adequate equipment to allow residents to call for assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from the residents bedside for 1 of 3 residents reviewed. (Resident C) Findings include:During an interview, on 9/22/2025 at 9:08 A.M., Resident C indicated he had no call light available. When Resident C moved into his room Maintenance came in, and he told the resident there was no spot to hook a call light up. He had been in the room for a few months, and had never received a call light. The facility provided a bell to ring, but he was unable to find it anymore. When he did have access to the bell staff were never able to hear it no matter how much he rang because he was located at the last room at the end of the hallway. Usually if he needed someone he would go into the bathroom and use the call light in there. There was one night he was unable to get out of bed, and needed to vomit and he had to yell out for help because he had no call light available. During an interview and observation, on 9/22/25 at 10:14 A.M., Registered Nurse (RN) 2 indicated Resident C used a wheelchair, and was able to make his needs known. The resident should have had a call light at the bedside at all times. During an observation with RN 2 in Resident C's room she confirmed there was no call light plugged into the wall above the residents bed. She identified where it should have been and asked Resident C if he had ever had a call light. Resident C replied he had not ever had a call light. During an interview, on 9/22/2025 at 10:40 A.M., the Maintenance Supervisor indicated he was aware there was no call light in Resident C's room. He said the room was a single room initially, so a second call light was never installed. A facility documented email was provided on 9/22/2025 at 1:50 P.M. by the Administrator, the email document titled call light boxes indicated that on 7/22/2025 they had not received the call light boxes yet and asked if they were on backorder. The next email was dated 9/22/2025 at 10:48 A.M. and stated following up here. An email reply was returned on 9/22/2025 at 1:01 P.M. and indicated the boxes were being shipped out that day. During an interview, on 9/22/2025 at 1:50 P.M., the Administrator indicated Resident C had a functioning call light now. The old call light for the room was hooked up. There were no additional emails from 7/22/2025 to 9/22/2025 about the call light boxes order.During an observation, on 9/22/2025 at 3:30 P.M., Resident C pressed his call light button while laying in bed. The light above the residents room door did not light up nor was there a sound. Resident C then hit the bell now placed on his bedside table three times, and then dropped the bell onto the floor. No staff responded from the sound. During an interview, on 9/22/2025 at 3:35 P.M., the Administrator indicated Resident C's call light was on and indicated the light overtop of the stairwell beside his room was the light associated with his call light not the light over his room. She also indicated there was no sound at the nurses station from the resident hitting the call light like the other call lights. The clinical record for Resident C was reviewed on 9/22/2025 at 3:00 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 6/26/2025, indicated the Resident was cognitively intact. The resident's diagnoses included, but were not limited to, hypertension, stroke, and depression. The resident was impaired on one side for upper and lower extremities. He used a wheelchair, and required moderate assistance with lower body dressing.The current facility policy, titled Answering the Call Light, with a revision date of August 2024, was provided by the Administrator on 9/22/2025 at 4:20 P.M. The policy indicated, .Be sure that the call light is plugged in and functioning at all time . Ensure that the call light is accessible to the resident when in bed .Report all defective call lights to the nurse supervisor promptly .3.1-19(u)

Based on observation and interview, the facility failed to maintain a functional, sanitary and comfortable homelike environment related to dripping and pooling water. This deficent practice had the potiential to affect 49 of 49 residents residing in the facility. Findings include: The first-floor dining room was observed on 06/19/25 at 8:32 A.M. The door was left open to the first-floor main hallway. The exterior wall had a large window, with a heating and air conditioning unit below the window in the center of the wall. Above the window unit on the ceiling, an area, approximately four feet long and three feet wide, was covered with a black spotted substance with brown staining all around the center, and visible moisture. A brown liquid substance dripped in three separate spots on the floor leaving half dollar sized brown stains on the floor. The stained ceiling was concaved outward, bowing down towards the floor. During an interview, on 06/19/25 at 11:03 A.M., Qualified Medication Aide (QMA) 1 indicated she had noticed the spot on the ceiling in April or May but didn't go in the dining room very often. The Maintenance Director had been in there multiple times, but she was unaware of what he was doing. During an interview, on 06/19/25 at 10:48 A.M., the Maintenance Director indicated he had found out about the leak the day before and he needed to take the heating and air conditioning unit out of the second-floor dining room. The unit on the second floor was not draining properly causing it to leak. He had replaced the unit in April of 2025. During an observation, on 06/19/25 at 11:08 A.M., the second-floor dining room had the door closed. Upon entrance the exterior wall had a large window with a heating and air conditioning unit below the window in the center of the wall. The cover was pulled off the unit and sitting to the left side. The unit was plugged into the wall and running at 72 degrees. There was a pool of water in front of it covering approximately 3 square floor tiles. During an observation in the first-floor dining room, on 06/19/25 at 1:19 P.M., a constant drip, with approximately a two second spacing, was coming from above the top of the windowsill near the ceiling. Water was pooling on the eight inch deep window sill, approximately one foot wide, and dripping into the air conditioning unit underneath the sill. Water was splattered on the floor in front of the air conditioning unit covering an area approximately one to two feet in front of the unit. During an observation and interview, on 06/19/25 at 1:35 P.M., in the activities room in the basement directly below the first-floor dining room. The exterior wall had a large window, with a heating and air conditioning unit below the window in the center of the wall. Above the window there was approximately a three foot long by one foot wide area on the ceiling that was concaved outward towards the floor leaving a small opening towards the window. A small amount of water was noted underneath the area on the windowsill. The Maintenance Director indicated the area was fixed two weeks ago and was from the unit on the first-floor leaking. The Social Services director indicated they usually had 12-15 residents in the room for activities, and at times, 50 people for events. During an interview, on 06/19/25 at 1:14 P.M., QMA 2 indicated there were currently nine residents living on the first floor. Six of them were independently mobile. Others walked the hallways regularly with therapy. The current facility policy, dated August of 2024, titled Homelike Environment, was provided by the Administrator on 06/19/25 at 1:00 P.M. The policy indicated, .Residents are provided with a safe, clean, comfortable and homelike environment .These characteristics include: clean, sanitary, and orderly environment . 3.1-19(f)(5)

Based on observation, interview, and record review, the facility failed to store medications appropriately related to labeling medications, cleanliness of medication carts, loose pills, discontinued medications, and expired medications for 2 of 3 Medication Carts reviewed (South Medication Cart on the third floor, North Medication Cart on the second floor) and 1 of 2 Medication Storage areas reviewed (First floor). Findings include: 1. The South Mediation Cart on the third floor was observed on 03/17/25 at 9:59 A.M., with Licensed Practical Nurse (LPN) 4 and contained the following: - An Albuterol inhaler, prescribed on 09/19/24, for Resident 12 , with no open date, - A small side drawer containing bottled liquid medications with a shiny film covering the bottom of the drawer, - One medium round white loose pill, - One small oval white loose pill, and The following cards of discontinued medications: - Cephalexin, an antibiotic, 500 milligrams (mg), 3 pills left, for Resident 13, - Guaifenesin, an expectorant, 600 mg, 3 pills left, for Resident 37, - Cefdinir, an antibiotic, 300 mg, 2 pills left, for Resident 14, - Macrobid, an antibiotic, 100 mg, 2 pills left, for Resident 14, - SMZ-TMP (Bactrim), an antibiotic, 800-160 mg, one pill left, for Resident 14, and - Dabigatran (Pradaxa), an anticoagulant, 150 mg, 3 pills left, for Resident 14. During an interview, at the time of observation, LPN 4 indicated, Resident 14 had been on three antibiotics because they were not working, or she was having a reaction. The Bactrim and the Macrobid had been delivered on 10/24/24. The Cefdinir was delivered in February. The discontinued medications should not have been in the Medication Cart. For discontinued medications, they had a bin they put them in located in the medication room and pharmacy would pick them up. The physician's orders were provided by the Director of Nursing (DON) on 03/17/25 at 1:07 P.M., and indicated the following: - Resident 14's Cefdinir was discontinued on 02/19/25, - Resident 14's Macrobid was discontinued on 10/28/24, - Resident 14's Bactrim was discontinued on 11/02/24, and - Resident 14's Pradaxa was discontinued on 10/26/24. 2. The North Medication Cart on the second floor was observed on 03/17/25 at 10:17 A.M., with LPN 5 and contained the following: - An Admelog insulin pen, 3/4 full, for Resident 17, with no open date, - A Basaglar/Lantus insulin pen, 1/3 full, for Resident 17, with an open date of 01/05/25, LPN 5 indicated it was good for 30 days after opening, - one medium round yellow loose pill, and - one large white oval loose pill. The physician's orders were provided by the DON on 03/17/25 at 1:07 P.M., and indicated the following: - Resident 17 received Admelog insulin, 5 units, on 03/16/25 at 9:00 P.M., and - Resident 17 received Lantus insulin, 4 units, on 03/17/25 at 9:00 A.M. 3. During an observation on 03/17/25 at 10:54 A.M., on the first floor, RN 6 indicated they did not really have a medication room on the first floor. They had a supply room, and a small, locked refrigerator located at the nurse's station. The refrigerator contained the following: - An open vial of Flu vaccine, delivered on 11/13/24, 1/2 full, with no open date noted on the vial or the box. During an interview, at the time of observation, RN 6 indicated the floor staff administered the flu vaccine to the incoming residents. During an interview, on 03/17/25 at 1:54 P.M., RN 6 indicated medications in the medication carts should be labeled with an open date when put into service. Discontinued medications should be removed from the medication carts and either returned to the pharmacy or destroyed based on the medication. The package insert for the Lantus insulin pen was provided by the DON on 03/17/25 at 2:23 P.M. The record indicated prefilled pens should be discarded after 28 days at room temperature or in use. The current Medication Labeling and Storage policy, with a revised date of 08/2024, was provided by the DON on 03/17/25 at 1:07 P.M. The policy indicated, .The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner .If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items .Multi-dose vials that have been opened or accessed .needle punctured .are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial . 3.1-25(j) 3.1-25(o)

Based on observation, interview, and record review, the facility failed to follow the manufacturer's guidelines related to insulin pen usage for 1 of 5 residents observed for medication administration. (Resident 12) Findings include: During an interview and observation with RN 7, on 03/12/25 at 11:13 A.M., medication administration was observed. The nurse prepared insulin for Resident 12 using an insulin pen. RN 7 indicated the resident was to receive 4 units of Aspart/Novolog insulin scheduled with meals and 6 units per the sliding scale, for a total of 10 units. The nurse removed the insulin pen from the medication cart, checked the label, removed the pen cap, cleaned the end of the pen with an alcohol wipe, applied the needle, and removed the cap of the needle. She turned the pen dose selector to two units, primed the pen holding the pen tip facing the floor, squirted out the two units of insulin, turned the pen dose selector to 10 units, donned gloves, and went into the resident's room. The nurse administered the insulin into the resident's abdomen. During an interview with RN 7, immediately following the procedure, she indicated the purpose of priming the insulin pen was to get the air out of the pen to ensure it would actually administer the insulin. When getting air out of a pen, they primed it to get it out. She was not trained on how to hold the pen when priming it, only to not hold it sideways. If it was a syringe, you would see the air and push it out holding it upright. If she wanted air out of the pen she should have held the insulin pen upright. The package insert for the Novolog insulin pen was provided by the Director of Nursing (DON) on 03/17/25 at 2:23 P.M. The instructions for use indicated, .Priming your Novolog .Pen .Turn the dose selector to select 2 units .Hold the Pen with the needle pointing up. Tap the top of the Pen gently a few times to let any air bubbles rise to the top .Hold the Pen with the needle pointing up. Press and hold in the dose button until the dose counter shows0 .A drop of insulin should be seen at the needle tip . The Electronic Medication Administration Record/Electronic Treatment Administration Record (EMAR/ETAR) for Resident 12 was reviewed on 03/17/25 at 2:26 P.M. The record indicated she had no critical Blood Sugar values prior to 03/12/25. The current Administering Medications policy, with a revised date of 08/2024, was provided by the DON on 03/17/25 at 1:07 P.M. The policy indicated, .Medications are administered in a safe and timely manner, and as prescribed . 3.1-37(a) 3.1-47(a)(1)

Based on observation, interview, and record review, the facility failed to ensure an accident hazard was thoroughly investigated after a resident acquired a fracture and laceration to her thumb for 1 of 3 residents reviewed for accident hazards. (Resident 13) Findings include: The clinical record for Resident 13 was reviewed on 03/12/25 at 3:04 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 02/10/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, a fracture of the left ilium, seizure disorder, anxiety, and severe intellectual disabilities. A Progress Note, dated 03/01/25 at 12:54 A.M., indicated Licensed Practical Nurse (LPN) 2 entered the resident's room and the resident was observed to have a laceration to her left thumb and the nail bed was red and discolored. During an interview, on 03/12/25 at 10:59 A.M., RN 7 indicated the resident could get herself in and out of her wheelchair, would crawl on the floor, and could only say a few simple words. During an observation, on 03/13/25 at 10:55 A.M., Resident 13 was sitting in her wheelchair in the hallway on the third floor. Her left thumb wound was closed and had light bruising. The accident investigation folder was reviewed on 03/14/25 at 10:50 A.M. The folder contained the incident report filed with the State Department of Health, an X-ray report dated, 02/28/25, a follow up orthopedic physician's visit, dated 03/05/25, and a note from the Assistant Director of Nursing (ADON). During an interview on 03/14/25 at 11:30 A.M., the Administrator indicated there wasn't much in the accident investigation folder, it was pretty cut and dry. During an interview on 03/14/25 at 3:39 P.M., LPN 2 indicated the night of the accident she was in another resident's room when the Certified Nurse Aide (CNA) asked her to come to Resident 13's room. She entered the room and saw blood on the resident's hand. She asked what happened, the resident looked at her and said eat. The CNA was unclear what had happened. LPN 2 cleaned the resident's hand, phoned the ADON and the on-call Nurse Practitioner (NP) who gave the order to send the resident to the emergency room to be evaluated. LPN 2 said she had looked on the wheelchair, the bed, and around the room, and found there was a small amount of blood located on the door frame next to the strike plate. She wrote a Progress Note and put information regarding the incident in the Risk Management part of the electronic health record. During an interview on 03/17/25 at 11:08 A.M., the ADON indicated LPN 2 phoned her and notified her of the accident to Resident 13. The resident was sent to the local emergency room to be treated. The resident wouldn't leave a bandage on her thumb. The wound was healing. The strike plate was taken off the resident's door. During an interview on 03/17/25 at 11:13 A.M., the Administrator indicated after learning of the accident involving Resident 13, she sent the maintenance man a text message requesting the strike plate on the door be removed. No other rooms were reviewed. The accident folder lacked any investigation of the other resident room strike plates or interviews with staff and cognitively intact residents. The current facility policy, titled Accidents and incidents - investigating and reporting, with an effective/revision date of 08/2024, was provided by the Director of Nursing on 03/17/25 at 1:07 P.M. The policy indicated, .All accidents and incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator .The following data, as applicable, shall be included on the Report of Incident/Accident form: .k. Any corrective action taken . 3.1-45(a)

Based on observation, interview, and record review, the facility failed to provide physician ordered nutritional supplements for 1 of 2 residents reviewed for nutrition. (Resident 29) Findings include: On 03/12/25 at 3:24 P.M., Resident 29 was observed in the Activity Room participating in an ice cream activity. The resident was very thin in appearance. The clinical record was reviewed on 03/12/25 at 2:58 P.M. The resident was admitted to the facility on [DATE]. A Quarterly Minimum Data Set (MDS) assessment, dated 02/20/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, depression, anxiety, cardiac arrhythmia, and malnutrition. The resident was 72 inches tall, weighed 105 pounds, and was on a physician prescribed weight gain program. The Admission MDS assessment, dated 11/11/24, indicated the resident had a diagnosis of malnutrition, was 72 inches tall, and weighed 113 pounds. The current Nutrition Care Plan, with an initiated date of 11/03/24, was provided by the Director of Nursing (DON) on 03/17/25 at 1:07 P.M. The Care Plan indicated the resident was at risk for malnutrition. The interventions included, but were not limited to, Provide and serve supplements as ordered with an initiated date of 11/09/24. An Admission Nutritional Risk Assessment, with an effective date of 11/07/24, indicated the resident had the nutritional supplement, Boost Plus, in use, three times a day, that was ordered by the MD/Nurse Practitioner (NP) at admission. The reason for the supplement was listed as the resident's risk for malnutrition. The resident's weight was 112 pounds and her Ideal Body Weight was listed as 160 pounds. The resident was underweight, had no chewing or swallowing problems, and needed one staff member to physically assist her with eating. The resident was on a regular diet with chopped meats. The November 2024 Electronic Medication Administration Record (EMAR) and the Progress Notes, that included the EMAR notes, were provided by the DON on 03/17/25 at 1:07 P.M. The records indicated the resident was to receive Boost Plus dietary supplement three times a day, with a start date of 11/01/24. The resident did not receive the supplement on the following dates and times: - On 11/06/24 at 9:00 A.M., 1:00 P.M., and 6:00 P.M., the resident's supplement was not available. - On 11/12/24 at 9:00 A.M., 1:00 P.M., and 6:00 P.M., the resident's supplement was not available. - On 11/13/24 at 6:00 P.M., the resident's supplement was not available. - On 11/14/24 at 9:00 A.M., 1:00 P.M., and 6:00 P.M., the resident's supplement was not available. During an interview, on 03/14/25 at 2:00 P.M., the Assistant Director of Nursing (ADON) indicated the pharmacy did not deliver Ensure (dietary supplements). The ADON indicated she ordered the resident's Ensure from another company. If she had a resident on Ensure, she had ordered it weekly. There had been times when they had ordered Ensure from an online retailer. If an order was given on a Friday, she could go to a local pharmacy and pick up Ensure. If they could get a case of it from the online retailer, then they went to a local store and picked up enough to last until the delivery was made. During an interview, on 03/17/25 at 2:02 P.M., Corporate Clinical Support indicated they did not have a policy related to following physician's orders. The current Resident Rights policy, with a revised date of 08/2024, was provided by the Director of Nursing on 03/17/25 at 1:07 P.M. The policy indicated, .Federal and state laws guarantee certain basic rights to all resident of this facility .equal access to quality care . 3.1-25(a) 3.1-46(a)(1)

Based on observation and interview, the facility failed to follow appropriate infection control guidelines during medication administration related to hand hygiene for 2 of 5 residents observed. (Residents 28 and 18) Findings include: Medication administration was observed on 03/12/25 at 9:05 A.M., with Qualified Medication Aide (QMA) 8. The QMA prepared a cup of medications and a cup of water for Resident 3. She passed the cups back and forth while assisting the resident, went back to the computer on the medication cart, touched the keys on the computer, then used hand sanitizer. The QMA proceeded to prepare medications for Resident 28, retrieving medications from the cart and documenting on the computer. She prepared a cup of medications, took the medications into the resident's room, donned gloves, administered eye drops, removed her gloves, took the cup of medications back out to the medication cart, and crushed them. She mixed the medications with a spoonful of applesauce, entered the resident's room and assisted the resident with their medications by spooning the mixture into her mouth. The QMA held the resident's insulated cup and touched the resident's straw using both hands during medication administration. The QMA went back to the medication cart, touched the computer keys, touched the mouse, unlocked the cart with a key and started preparing medications for Resident 18. The QMA failed to use hand sanitizer or wash her hands and continued touching the keyboard of the computer, the mouse, medication cards, the medication cart keys, the medicine cup of pills and the water cup. The QMA used hand sanitizer then entered Resident 18's room to administer her medications. During an interview, immediately following the observation, the QMA indicated staff should use hand sanitizer between residents. If a staff members' hands were soiled, they should wash them with soap and water. The current Handwashing and Hand Hygiene policy, with a revised date of 08/2024, was provided by the Director of Nursing on 03/17/25 at 2:23 P.M. The policy indicated, .Hand hygiene is indicated .after touching the resident's environment . The current Administering Medications policy, with a revised date of 08/2024, was provided by the Director of Nursing on 03/17/25 at 1:07 P.M. The policy indicated, .Medications are administered in a safe and timely manner .Staff follows established facility infection control procedures .handwashing .for the administration of medications . 3.1-18(l)

Based on observation and interview, the facility failed to store food appropriately for 1 of 2 kitchen observations. Findings include: During an observation on 10/02/24 at 9:40 A.M., of the facilities kitchen refrigerators and dry storage the following was observed: - an undated, sealed gallon sized bag half full of cooked ham, - an undated, sealed gallon sized bag half full of cooked taco meat, - a square lidded container, approximately quart sized, filled with country gravy with a prepared date of 09/27/24, and a discard date of 08/01/24, - an undated resident's left over pizza box with pizza inside, - a gallon of mustard opened, 3/4 full, with a manufacturer best if used by date of 02/10/24, - two gallons of milk, one unopened and one 3/4 full, with a manufacturer best if used by date of 10/01/24. - an unopened dented gallon can of mandarin oranges was on the front of the dry food storage shelf. During an interview with [NAME] 2 on 10/02/24 at 9:55 A.M., she indicated that the kitchen serves 34 to 36 residents. All the food items that were undated or outdated would be thrown away. During an interview with [NAME] 2 on 10/02/24 at 1:31 P.M., she indicated that the refrigerators should be checked daily. Cooked foods are only good for three days stored in the refrigerator, and they were supposed to date them as soon as they put them in the refrigerator. The pizza box found in the fridge earlier that morning was a resident's. All resident food that was left over should not be put in the kitchen fridge. She was unsure which resident's pizza it was. During an interview with Resident B on 10/02/24 at 10:58 A.M., they indicated that they had been served spoiled meat, sour broccoli, spoiled milk and juices before. A current facility policy titled Kitchen Operations: Food storage, was provided by the DON (Director of Nursing) on 10/02/24 at 1:25 P.M., with a revision date of January of 2023, stated .severely dented cans . should be exposed of promptly .Leftover prepared foods .must clearly be labeled with the name of the product, the date it was prepared, and marked to indicate the date by which the food shall be consumed or discarded. Leftover foods can be held at 41 degrees Fahrenheit or less for no more than three days .each nursing unit with a refrigerator used to store food/beverage items for resident consumption . This citation relates to Complaint IN00442330. 3.1-21(i)(1) and (3)

Based on interview and record review, the facility failed to thoroughly investigate a resident's allegation of abuse for 1 of 1 abuse allegations reviewed. (Resident B) Findings include: During an interview on 08/13/24 at 10:14 A.M., the SSD (Social Services Director) indicated Resident B made some allegations of physical abuse during a meeting on 08/08/24. The SSD followed up with the resident for 72 hours related to the allegations and the resident did not repeat the allegations or have any other concerns. She did not interview any other residents about abuse. When she brought the allegation to the Administrator, he took over the investigation. The incident was reported to the State Department of Health by the Administrator on 08/08/24 at 3:28 P.M. The brief description of the incident indicated the resident told a social worker she had been locked in her closet and locked in her room and that someone choked her at night. The resident stated she had a bruise above her eye. The resident was assessed and had no bruising above her eye or on her throat. The resident had a cupboard for clothing that did not lock and there were no locks on the residents' room doors. The resident's Psychiatric Health Care Provider was notified of the resident's increased hallucinations and would look at adjusting the resident's medications at their next visit. The resident's clinical record was reviewed on 08/12/24 at 7:26 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 07/30/24, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, alcohol abuse with alcohol-induced psychotic disorder with hallucination, anxiety, depression, and seizure disorder. The resident resided on the third floor of the facility. During an interview on 08/13/24 at 10:43 A.M., the Administrator indicated the SSD came to him with the resident's allegations. He typed up the reportable and sent it to the State. They looked at the complaint. The resident had no closets to lock her in, and no locks on her doors. The resident reported being choked, but the resident was assessed and had no injuries. Normally, they would interview the other residents that resided on the same floor the resident lived on, but they were all too confused and non-interviewable. The DON (Director of Nursing) may have assessed the non-interviewable residents for signs or symptoms of abuse. During an interview on 08/13/24 at 11:52 A.M., the DON indicated she completed a head-to-toe assessment of Resident B, with no findings. She assessed the other residents that resided on the third floor on the side of the hall that Resident B lived on. There were some residents that were interviewable that lived on the third floor. She did not ask any of the interviewable residents about abuse. She thought the SSD was interviewing residents. Several residents could have been interviewed; she did physical assessments on residents that were not interviewable. A document signed by the DON on 08/09/24 at 2:00 P.M., indicated the names and room numbers of the seven residents that were assessed and found to have no bruising or skin discoloration. A Bed Board for 08/09/24 indicated twenty residents resided on the third floor at the time the allegation of abuse was made. Seven of those residents (Residents B, E, F, G, H, J, and K) were assessed for bruises and skin discoloration. The other thirteen residents (Residents L, M, N, O, P, Q, R, S, T, V, W, X, and Z) that lived on the third floor were not assessed for signs or symptoms of abuse. Of the thirteen residents not assessed, six of them (Residents L, M, S, V, W, and X) were determined to be cognitively intact and interviewable based on their most recent MDS assessments. The current facility policy, titled Accidents/Incidents/Investigation, with an effective date of 10/2022, was provided by the Administrator on 08/13/24 at 1:25 P.M. The policy indicated, .All accidents or incidents involving residents .shall be investigated .The following data, as applicable, shall be included .Other pertinent data as necessary or required . This citation relates to Complaint IN00440606. 3.1-28(d)

Based on interview and record review, the facility failed to ensure a complete and accurate facility assessment based on the resident population and identification of resources needed to provide the necessary care and services required for their residents for 1 of 1 assessment reviewed. Finding includes: On 02/05/24 at 11:00 A.M., the Administrator provided a facility assessment form dated 12/27/23. The form was incomplete related to the care areas and population of residents in the facility and the number of residents in each care area. The form lacked resources needed during emergencies. The form lacked training topics and competencies specific to the facility. The form lacked physical environment and building/plant needs. On 02/09/24 at 2:17 P.M., the Administrator indicated he and the Director of Nursing started working on the facility assessment in November 2023. He acknowledged the facility assessment was incomplete and didn't show an accurate picture of the facility. The current facility policy, titled Facility assessment Policy, with a revision date of 06/2022, was provided by the Administrator on 02/09/24 at 2:55 P.M. The policy indicated, .The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for the residents competently during both day-to-day operations and emergencies .

Based on observation, interview, and record review, the facility failed to provide a homelike setting for 7 of 14 residents using the shower rooms on the 100 Hall related to loose wires hanging from the walls. Findings include: On 02/07/24 at 10:11 A.M., Shower room [ROOM NUMBER] on the 100 Hall was observed. Four black electrical wires were running from a hole in the wall near the ceiling, behind the entrance door, down to the floor with the ends of the wires bundled and wound back and forth laying on the floor. The ends of the wires were wrapped with blue paper-like tape. The bundle was approximately 12 inches by 4 inches and the full length of the bundle was laying flat against the floor. During an observation and interview on 02/08/24 at 12:12 P.M., Shower room [ROOM NUMBER] on the 100 Hall had four black electrical wires hanging from a hole in the wall near the ceiling above the entrance door. The wires were draped over a second door in the shower room that led to the toilet area and hung down the door to about two feet from the floor. The ends of the wires were wrapped in blue paper-like tape. CNA (Certified Nurse Aide) 7 indicated the shower rooms had been remodeled and the wires in both shower rooms had been this way since October of 2023. The residents currently used both shower rooms. During an interview on 02/08/24 at 12:29 P.M., Resident 33 indicated she had used both shower rooms recently. During an interview and observation on 02/08/24 at 12:35 P.M., the Maintenance Director indicated the wires were from the old call light system and were to be used for the future call light system. The wires were currently dead. The shower rooms had been remodeled since September of 2023, and the wires had been hanging there since that time. He verified the wire ends were wrapped in painter's tape, not electrical tape. Shower rooms [ROOM NUMBERS] were observed on 02/08/24 at 3:19 P.M. The wires had been cut off at the wall and capped with red and yellow wire caps. During an interview on 02/08/24 at 3:20 P.M., the Administrator indicated he had the Maintenance Director test the wires, cut the wires off, cap them, and put fire caulk around the wires. He did not know why the Maintenance Director decided to cut the wires off today. During an interview on 02/09/24 at 11:00 A.M., the Maintenance Director indicated it was an executive decision after he had spoken with the Administrator to cut the wires. They had verified there was no power going to them, it was a dead system. He was told by the contractors to leave them for the new system they would be installing. The original quote for the call light system, dated 10/11/23, was provided by the [NAME] President of Clinical Services on 02/09/24 at 2:29 P.M. He indicated the contract was just for the first floor of the building and the remodel should be finished by the middle of the first quarter of the year 2024. The quote did not list a specific date the call system was to be completed. The current facility Admission Agreement provided at the Entrance Conference indicated, .The resident has a right to a safe, clean, comfortable and homelike environment . 3.1-19(f)(5)

Based on observation, record review, and interview, the facility failed to ensure care plans were in place for residents related to a risk for skin impairments, resident's oral health status; and a care plan/physician's order related to the adequate assessment, and ongoing monitoring for the use of a seat belt and body positioning device for 3 of 14 residents reviewed for care plans. (Residents 14, 25, and 2) Findings include: 1. On 02/07/24 at 3:25 P.M., Resident 14 was observed to have an open area on his right buttock. The Wound Nurse indicated the area was newly identified and a dressing was placed on the wound daily. The clinical record for Resident 14 was reviewed on 02/07/24 at 3:41 P.M. An Annual MDS (Minimum Data Set) assessment, dated 12/11/23, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited, coronary artery disease, hypertension, chronic obstructive pulmonary disease, arthritis, and depression. The resident was at risk for skin break down and required assistance with transfers. The resident's complete Care Plan was provided by the DON (Director of Nursing) on 02/09/24 at 11:40 A.M. and lacked a care plan related to the resident's at risk for skin break down status. During an interview on 02/09/24 at 1:50 P.M., the DON indicated the resident previously had a care plan related to his risk for skin break down. The care plan was discontinued. She was unsure why the resident no longer had an at risk for skin break down care plan. 38239 2. Resident 25 was observed on 02/06/24 at 11:18 A.M. The resident was missing several teeth. The resident indicated she was missing teeth and had some cavities she wanted worked on. She wanted to see the dentist. She told a staff member, but she was not sure who it was. She had been in the facility since July of 2023. The resident's clinical record was reviewed on 02/08/24 at 2:29 P.M. An Admission MDS assessment, dated 07/12/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, diabetes, heart failure, and renal disease. The assessment indicated the resident had obvious or likely cavities or broken natural teeth. The Care Area Assessment Summary section of the assessment indicated that the Dental Care care area triggered and should be addressed in the resident's care plan. The resident's complete Care Plan was provided by the DON on 02/09/24 at 11:40 A.M. and lacked a care plan related to the resident's oral status. During an interview on 02/09/24 at 1:50 P.M., the DON indicated the resident did sign up for ancillary services that included dental services upon admission. There were some issues with the resident's insurance. The resident was on the list to see the dentist at the end of this month. She was not sure why the resident did not have a care plan for her oral status. 3. On 02/07/24 at 10:03 A.M., Resident 3 was observed in her room sitting upright in her wheelchair. A body positioning device was attached to the back of the resident's wheelchair with straps on each side of the resident's seat. The device went over the resident's shoulders and buckled on each side of the resident's trunk. A seat belt was also in place and buckled across the resident's midsection at the hips. During an interview on 02/07/24 at 10:18 A.M., RN 3 indicated the resident had a seat belt and a harness type positioning device. She wasn't sure if the resident had an order for the devices. Nursing staff did not document monitoring of the devices that she was aware of. The resident's record was reviewed on 02/07/24 at 11:00 A.M. An Annual MDS (Minimum Data Set) assessment, dated 12/19/23, indicated the resident's memory was impaired. The diagnoses included, but were not limited to, seizure disorder, severe intellectual disabilities, and diabetes. The resident's lower extremities were impaired. The resident required substantial/maximal assistance for eating and upper body dressing and was totally dependent on staff for assistance with all other ADLs (Activities of Daily Living). The resident's record lacked a physician's order for the positioning device or seat belt; a care plan for the assessment for use of the devices, and documentation of ongoing monitoring of the use of the devices. During an interview on 02/07/24 at 10:27 A.M., the DON (Director of Nursing) indicated the resident did have a seat belt and positioning device. There should be a physician's order for the seat belt and positioning device and orders to monitor the resident when the devices were being used. The current facility policy, titled Comprehensive Care Plan Guideline, with a revision date of 08/2022, was provided by the [NAME] President of Clinical Services on 02/09/24 at 2:31 P.M. The policy indicated, .To ensure appropriateness of services and communication that will meet the resident's needs .in accordance with state and federal regulations .Care plan interventions should be reflective of risk area(s) or disease processes that impact the individual resident . 3.1-35(a)

Based on observation, interview, and record review, the facility failed to follow physician's orders for insulin administration (Resident 22) and and follow manufacturer's guidelines related to insulin pen usage (Resident 24) for 2 of 6 residents observed for Quality of Care. Findings include: 1. The clinical record for Resident 22 was reviewed on 02/06/24 at 3:20 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 12/22/23, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, dementia, hypertension, diabetes, anxiety, and depression. A physician's order, dated of 09/18/23 through 02/02/24, indicated the resident was to receive Insulin Glargine Solution 100 units per ml (milliliter). The staff were to inject 30 units subcutaneously one time a day for diabetes, hold if blood sugar was less than 120 mg/dl (milligrams per deciliter). The EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) for December 2023, January and February 2024, indicated the resident had received the insulin medication when the blood sugar was less than 120 mg/dl for the following dates: - On 12/02/23 the resident's blood sugar was 104. - On 12/08/23 the resident's blood sugar was 104. - On 12/17/23 the resident's blood sugar was 112. - On 12/18/23 the resident's blood sugar was 114. - On 12/19/23 the resident's blood sugar was 82. - On 12/20/23 the resident's blood sugar was 95. - On 12/22/23 the resident's blood sugar was 92 - On 12/23/23 the resident's blood sugar was 95. - On 12/24/23 the resident's blood sugar was 101. - On 12/25/23 the resident's blood sugar was 78. - On 12/26/23 the resident's blood sugar was 89. - On 01/01/24 the resident's blood sugar was 108. - On 01/02/24 the resident's blood sugar was 91. - On 01/03/24 the resident's blood sugar was 113. - On 01/08/24 the resident's blood sugar was 93. - On 01/13/24 the resident's blood sugar was 112. - On 01/14/24 the resident's blood sugar was 96. - On 01/16/24 the resident's blood sugar was 102. - On 01/17/24 the resident's blood sugar was 118. - On 01/18/24 the resident's blood sugar was 83. - On 01/20/24 the resident's blood sugar was 86. - On 01/21/24 the resident's blood sugar was 77. - On 01/22/24 the resident's blood sugar was 107. - On 01/23/24 the resident's blood sugar was 99. - On 01/29/24 the resident's blood sugar was 119. - On 02/01/24 the resident's blood sugar was 85. - On 02/02/24 the resident's blood sugar was 79. On 02/08/24 at 10:57 A.M., RN 3 indicated if a resident had a routine insulin medication, she would use the blood sugar reading that was taken earlier that morning. If there were hold parameters for the medication the physician's orders should have been followed. The current facility policy titled Medication Administration and General Guidelines was provided by the Director of Nursing on 02/08/24 at 12:44 P.M. The policy indicated .Medications are administered in accordance with written orders of the attending physician . 34232 2. Medication administration was observed on 02/08/24 at 8:42 A.M., with RN 5 as she prepared insulin pens for Resident 24. The RN gathered a Lispro insulin pen and a Lantus insulin pen from a plastic bag and indicated the resident was to receive 17 units of Lispro (a short-acting insulin) with meals and 40 units of Lantus (a long acting insulin). The resident's blood glucose level had been 178. The nurse applied needles to both pens, not wiping off the rubber seal with an alcohol wipe, turned the dial at the end of the pens to the appropriate dose, used hand sanitizer, entered the resident's room, cleaned the resident's abdomen with an alcohol wipe, donned gloves, verified the resident's name, administered the two insulins, holding the pens in place for a few seconds following administration, and exited the room. During an interview following the administration of the insulin, the RN indicated when preparing an insulin pen for use, she would wipe off the insulin pen tip with an alcohol wipe, apply the needle, turn the pen to the required dose, and administer the insulin. After conferring with QMA (Qualified Medication Aide) 6, the RN indicated you should prime the insulin pen before use. The clinical record for Resident 24 was reviewed on 02/08/24 at 9:45 A.M. A Quarterly MDS assessment, dated 01/18/24, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, diabetes and renal insufficiency. The Lantus insulin package insert was provided by the [NAME] President of Clinical Services on 02/08/24 at 3:05 P.M. The record indicated, .HOW TO USE YOUR LANTUS .PEN .Wipe the pen tip (rubber seal) with an alcohol swab .Remove the protective seal from the new needle, line the needle up straight with the pen, and screw the needle on .after you have attached the needle, take off the outer needle cap and save it .Remove the inner needle cap and throw it away . PERFORM A SAFETY TEST .Dial a test dose of 2 units .Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose .Press the injection button all the way in and check to see that insulin comes out of the needle . The Lispro insulin package insert was provided by the [NAME] President of Clinical Services on 02/09/24 at 3:32 P.M. The record indicated, .INSTRUCTIONS FOR USE .Pull the Pen Cap straight off .Wipe the Rubber Seal with an alcohol swab .push the capped Needle straight onto the Pen .Pull off the Outer Needle Shield .Pull off the Inner Needle Shield .Prime before each injection .Priming you Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly .If you do not prime before each injection, you may get too much or too little insulin .To prime your Pen, turn the Dose Knob to select 2 units .Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top .Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window .You should see insulin at the tip of the Needle . The current Medication Administration and General Guidelines policy, 2020 Edition, was provided by the [NAME] President of Clinical Services on 02/09/24 at 3:32 P.M. The policy indicated, .Medications are administered .using good nursing principles and practices . 3.1-37(b)

Based on observation, interview, and record review, the facility failed to transfer a resident, that required a full body mechanical lift, safely using the appropriate lift resulting in a fracture for 1 of 3 residents reviewed for accidents. (Resident C) Findings include: On 8/9/23 at 11:08 a.m., the Director of Nursing (DON) indicated on 7/27/23 Resident C was being assisted into bed with a lift. The resident yelled out in pain and was sent out to the emergency room (ER). The resident had a fractured left fibula and a follow up appointment with Orthopedics. During an observation and interview on 8/9/23 at 1:57 p.m., Resident C was lying in her bed, her left leg was wrapped and elevated on a pillow. She indicated she required a full body mechanical lift for transfers. On 7/27/23, the day of the incident, she was in the wheelchair for a long time and had asked to be put to bed. The full body mechanical lift had quit working. The staff couldn't find a cord to charge it, so they use a standing aid transfer system (required partial weight bearing) to transfer her to the bed. The resident had asked them not to use the standing aid unit. The staff indicated she had to use it or she could not get back to bed. The Certified Nursing Aides (CNAs) held the back of her pants and had an arm under each of her arms as they assisted her to stand up. She told them to set her back in the chair, but they wouldn't. They rolled her over to the bed, then swung her legs onto the bed. The clinical record for Resident C was reviewed on 8/9/23 at 12:48 p.m. A Quarterly MDS (Minimum Data Set) assessment, dated 6/30/23, indicated the resident was cognitively intact. She required extensive assistance of two or more staff members for mobility, transfers, and toilet use. She was 67 inches tall and weighed 263. The resident's diagnoses included, but were not limit to, cirrhosis of the liver, chronic kidney disease Stage 3, weakness, and anxiety. A Care Plan, with a revision date of 12/18/22, indicated the resident had an Activities of Daily Living (ADL) self-care performance deficit, related to immobility. The interventions indicated the resident required a mechanical lift with two staff assistance for transfers. The resident's record lacked documentation related to the transfer on 7/27/23 at 6:15 p.m. A Progress Note, dated 7/27/23 at 10:34 p.m., indicated Resident C started to complain of chest pain and right foot pain. The right foot was unremarkable. The resident stated that the chest pain was like when she had an MI (Myocardial Infarction). The staff called 911 and the local ER was notified. A Progress Note, dated 7/28/23 at 5:13 a.m., indicated the resident would be returning to the facility with a fracture of the left fibula. An Orthopedic Report, dated 8/1/23, indicated the resident was non-ambulatory at baseline. An x-ray of the left ankle indicated a nondisplaced distal fibula fracture. During an interview on 8/10/23 at 11:17 a.m., CNA 3 indicated on 7/27/23 Resident C had been up since that morning because she had an appointment. The full body mechanical lift (non-weight bearing) was how they got her up that morning, and she was insisting that she had to lay down. Her family member was in the room at the time. They went to get the full body mechanical lift and it was not operating correctly. There was concern for the resident's safety. The nurse was notified, and the care plan only stated, mechanical lift with two assists. It was explained we could use the standing aid transfer system and the resident agreed. Because she was a large person, for safety, a third CNA assisted with the transfer. The standing aid transfer system was placed in front of her, with one staff on each side, one behind her, and her family member in front. She was assisted to a somewhat standing position and the lift pad used with the full body mechanical lift was attached to the standing aid transfer system. During the pivot of the standing aid transfer system the resident cried out indicating she was in pain. She was lowered to her bed, laid down, placed in a comfortable position, and the nurse was notified. During an interview on 8/10/23 at 10:56 a.m., Licensed Practical Nurse (LPN) 2 indicated on the day of the incident (7/27/23) she was the day shift nurse. The incident occurred during the nursing shift change (6:15 p.m.). Resident C had been up since the 1:00 p.m. smoke break and was insisting she wanted to lay down. The CNAs went to get the full body mechanical lift and it was not working. They notified the nurse and the only plausible solution for immediate transfer was by using the standing aid transfer system. The resident was agreeable to the standing aid transfer system, because she insisted, she was not going to sit up all night. They normally used the full body mechanical lift for her transfers, but her care plan only indicated a mechanical lift with two-assist. To ensure her safety a third CNA was sent into the room to assist with the other two staff doing the transfer. She had not contact maintenance about the full body lift since the girls had already posted in the notification that the full body lift was down (not working) twice. During an interview on 8/10/23 at 10:12 a.m., the DON indicated when the facility rented the full body mechanical lift, and it was not working the decision was made to use the standing aid transfer system to put the resident in bed. The resident's requested to go to bed. The resident was agreeable to use the standing aid transfer system. She just wanted to get to bed. A third CNA was sent in to assist the other two CNAs for safety. The resident's family member was also present in the room during the transfer. The CNAs had indicated that as they were turning the standing aid transfer system, the resident stated, oh my leg, and they immediately sat her on the edge of the bed with the unit. A Physical Therapy Discharge Summary, dated 12/28/22 through 1/31/23, provided by the PT (Physical Therapy) Manager on 8/10/23 at 1:47 p.m., indicated Resident C was non-ambulatory. During an interview on 8/10/23 at 1:48 p.m., the PT Manager indicated the standing aid transfer system was a mobility frame sit to stand unit. It was primarily used by the therapy department. There were only two nurses who had been trained to use the mobility frame and it had never been used with Resident C. A Physical Therapy Evaluation and Plan of Treatment, dated 12/28/22, indicated Resident C required assistance for transfers using a full body mechanical lift. During an interview on 8/10/23 at 1:57 p.m., the DON indicated the Fire Department was not contacted for assistance with a transfer for Resident C on 7/27/23. During an interview and observation on 8/10/23 at 2:03 p.m., CNA 4 demonstrated to the DON how the standing aid transfer system was to be used. The DON indicated she was not aware the unit was not a mechanical lift. During an interview on 8/10/23 at 3:06 p.m., the DON indicated there were 14 residents that resided in the facility that required a full body mechanical lift for transfers. The full body mechanical lift was fixed on 7/28/23. The current facility policy, titled Resident Transfers , with a revision date of 9/2022, was provided by the DON on 8/10/23 at 1:45 p.m. The policy indicated, .to ensure the safety of residents and staff when performing mobility/transfer task .SOP DETAILS .1. Shall determine the type of transfer device, amount of assistance required to assist with safe mobility .b. weight bearing status .3. Determine the amount of assistance required for transfers and record this on the .Resident Care Plan . The current facility policy, titled Accidents/Incidents/Investigation, with a revision date of 10/2022, was provided by the DON on 8/10/23 at 1:45 p.m. The policy indicated, .3. In compliance with current rules and regulations governing accidents and or incidents involving a medical device . This Federal tag relates to Complaints IN00414379 and IN00413989. 3.1-45(a)

Based on observation, interview, and record review, the facility failed to ensure residents had not acquired in house pressure ulcers and the worsening of pressure ulcers for 3 of 4 residents reviewed for pressure ulcers. This deficient practice resulted in two residents' pressure ulcers worsening to a Stage 4 and Stage 3 and one residents' wound identified as a deep tissue injury. (Residents 25, 9, and 13) Findings include: 1. During an interview and observation on 01/03/23 at 12:04 P.M., Resident 25's right elbow was in a padded heel protector. The resident indicated he had an open wound on his right elbow. The clinical record for Resident 25 was reviewed on 01/05/23 at 12:17 P.M. The 5 day MDS (Minimum Data Set) assessment, dated 10/13/22, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, hypertension, hemiparesis, anxiety, depression, and dementia. The resident required the extensive assistance of one staff member for most ADLs (Activities of Daily Living). The resident was at risk for developing pressure ulcer and had no pressure ulcers at the time of the assessment. An Initial Wound Assessment, dated 11/09/22, indicated the resident had a Stage 2 (full thickness tissue loss) pressure ulcer on his right elbow measuring 3 cm (centimeter) x (by) 2 cm x 0.1 cm. The pressure ulcer was acquired in the facility. The treatment was to apply a medicated pink foam dressing every three days. An additional order was included on the ETAR (Electronic Treatment Administration Record) to ensure the pink dressing was intact to the right elbow every shift. The ETAR lacked documentation nursing staff ensured the dressing was in place from 11/09/22 to 11/14/22. On 11/15/22 A new treatment was obtained to cleanse the right elbow with normal saline or sterile water, apply honey gel and cover with bordered foam dressing every day and as needed for soilage. The ETAR indicated the treatments were completed as ordered except for 11/20/22, when the resident refused. A Weekly Wound Assessment, dated 11/16/22, indicated the resident had a Stage 2 pressure ulcer on his right elbow measuring 3 cm x 2 cm x 0.2 cm. A Weekly Wound Assessment, dated 11/23/22, indicated the resident was seen by the wound doctor in the facility. The pressure ulcer on the right elbow had worsened and was now a Stage 4(full thickness tissue loss with bone, tendon, or muscle exposed, slough or eschar maybe present). The wound measured 3 cm x 3 cm x 1 cm. The resident was sent to the local hospital on 11/23/22 for cellulitis and wound evaluation of the right elbow and returned on 12/01/22. A Weekly Wound Assessment, dated 12/07/22, indicated the resident had a Stage 4 pressure ulcer on his right elbow measuring 2.5 cm x 2 cm x 0.7 cm. A Weekly Wound Assessment, dated 12/28/22, indicated the resident had a Stage 4 pressure ulcer on his right elbow measuring 1.7 cm x 1.2 cm x 0.2 cm. During an interview on 01/09/23 at 12:03 P.M., RN 2 indicated the resident was added to her wound rounding list on 11/09/22 when the Stage 2 pressure ulcer was discovered. Prior to the development of the pressure ulcer the resident had pain relieving patches placed on the right elbow and believed that was what caused the pressure. His wound was evaluated weekly. 38769 2. During an interview on 01/03/23 at 1:44 P.M., Resident 9 indicated she had a wound on her right heel. She would go to the wound clinic once a week and they would change the dressing there. The facility no longer changed the dressing. She had the wound for several months. The clinical record for Resident 9 was reviewed on 01/04/23 at 3:33 P.M. A Quarterly MDS assessment, dated 11/20/22, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, acute osteomyelitis of the right ankle and foot, anemia, diabetes, and sacral spina bifida. The resident had impairments to both sides of the lower extremities and a diabetic foot ulcer. A Progress Note, dated 08/08/22 at 4:06 P.M., indicated staff called the ADON to the resident's room. The resident had an open area to the right heel that was a Stage 2 pressure area. New orders were obtained to cleanse the wound bed with wound cleanser, apply collagen to the right heel wound bed, and cover with a dry dressing. An Initial Wound Assessment, dated 08/08/22, indicated the resident right heel wound measured 1.3 cm x 1.3 cm x 0.2 cm. A Weekly Wound Assessment, dated 08/10/22, indicated the resident had a diabetic wound to the right heel that was acquired in house. The wound measured 1.3 cm x 1.3 cm x 0.2 cm. There was 76 to 100% (percent) granulation tissue to the wound bed. A Weekly Wound Assessment, dated 09/07/22, indicated the resident had a diabetic wound to the right heel that was acquired in house. The wound measured 2 cm x 1.9 cm x 0.2 cm. There was 76 to 100 % epithelial tissue present. The wound had deteriorated. A Weekly Wound Assessment, dated 10/12/22, indicated the resident had a diabetic wound to the right heel that was acquired in house. The wound measured 2.5 cm x 2 cm x 0.3 cm. There was 0 to 25% granulation tissue and 51 to 75% slough. The wound was improving. A Weekly Wound Assessment, dated 12/14/22, indicated the resident had a diabetic wound to the right heel that was acquired in house. The wound measured 1.7 cm x 1.2 cm. There was 76-100% epithelial tissue present. The wound was improving. No current wound measurements were provided from the wound clinic or the facility. The clinical record including the August, September, October, and November 2022 EMAR/ETAR lacked documentation that the right heel wound treatment was completed as ordered on the following dates: - 08/20/22, - 08/21/22, - 09/11/22, - 09/19/22, - 10/10/22, - 11/02/22, - 11/28/22, and - 11/29/22. The clinical record lacked documentation that the resident had any preventative interventions in place for the right heel prior to the wound developing. An intervention to elevate the right heel off the bed with pillows while in bed was initiated on 09/12/22, after the wound was identified on 8/8/22 A Wound Clinic Visit Note, dated 10/10/22 and 11/21/22, indicated the resident was seen for a wound check of a Stage 3 (full thickness skin loss involving damage or necrosis of subcutaneous tissue) pressure ulcer to the right heel. A Progress Note, dated 08/10/22 at 2:54 P.M., indicated a new order was obtained to cleanse the wound with normal saline or sterile water, apply alginate to the right heel wound bed, and cover with a clean dressing, daily. A Progress Note, dated 09/12/22 at 4:58 P.M., indicated the resident was seen by an outside wound clinic. New orders were obtained for Dakin's wet to dry dressing to the right heel daily, and make sure the right heel is elevated off the bed with pillows. A Progress Note, dated 11/07/22 at 12:49 P.M., indicated the resident's right leg was noted to be angry red, warm to touch, with 2+ pitting edema. The resident was to be seen at the outside wound clinic for an appointment later in the day. A Progress Note, dated 11/11/22 at 4:34 P.M., indicated the writer had received report from the local hospital. The resident had been receiving treatment for osteomyelitis and MRSA of the right foot. The nurse reported the resident had a PICC line in the right upper extremity and was receiving IV antibiotics. The treatment for the right heel was to administer Dakin's 1/4 strength solution to the wound daily. The complete Care Plan was provided by the DON on 01/06/23 at 3:06 P.M. A diabetic ulcer to the right foot Care Plan was developed on 01/04/23, indicated the following: - avoid exposure to temperature extremes: heating pads, hot water bottles, heat lamps, hot or cold solutions and socks, sunburn, icepacks, - avoid mechanical trauma, - diet as ordered, - encourage and assist resident to reposition frequently, - ensure appropriate protective devices are applied to affected areas, - labs as ordered, - meds as ordered, - monitor blood sugar levels, - monitor and document wound size, - monitor, document, and report any sign or symptoms of infection, - monitor, document, and report any changes in wound, - NAR (Nutritionally at Risk) to follow, and - refer to foot care nurse or podiatrist. An at risk for skin integrity Care Plan, with a start date of 02/22/22, indicated the following: - diet as ordered, started 11/17/22 - educate resident, family, caregivers of causative factors and measures to prevent skin injury, started 02/22/22, - encourage good nutrition and hydration to promote healthier skin, started 02/22/22, - follow facility protocols for treatment of injury, started 02/22/22, - keep skin clean and dry, use lotion on dry skin, started 02/22/22, - labs as ordered, started 02/22/22, - observe skin with daily cares, notify the nurse of any new or worsening areas, started 02/22/22, and - treatments as ordered, started 11/17/22. During an interview on 01/05/23 at 9:26 A.M., QMA (Qualified Medication Aide) 4 indicated the resident needed assistance with showers. She had a wound on one of her legs that she went to the wound clinic for. She was compliant with care. During an interview on 01/05/23 at 5:37 P.M., the Wound Clinic Nurse indicated the resident had been receiving wound care services for a Stage 3 pressure ulcer to the right heel since 09/12/22. The wound was a Stage 3 at the first appointment prior to debridement. Currently, the wound had greatly improved since the resident first came in for treatment. On 12/20/22, the wound clinic changed the resident's orders and indicated that the facility was no longer to change the dressings. It was only changed once a week at the wound clinic. The resident had been sent to the hospital from her appointment on 11/07/22 for osteomyelitis in the wound. During an interview on 01/06/23 at 10:06 A.M., RN 2 indicated she started following the resident's wound on 09/14/22. The wound was identified by the facility on 08/08/22 as a diabetic ulcer. The resident had started going to the wound clinic on 09/12/22. In November she was sent from a wound clinic appointment to the hospital with osteomyelitis. If the wound clinic classified a wound as a pressure ulcer, then the facility should change their documentation of the wound. The treatments should be completed per the MD orders. During an interview on 01/09/23 at 2:32 P.M., RN 2 indicated she was unsure of what caused the wound on the resident's heel. 34232 3. During an observation and interview on 01/03/23 at 12:34 P.M., Resident 13 was sitting in his wheelchair in his room. He was wearing non-skid socks. He indicated he had a blister on his left heel. He took off his sock and revealed an island dressing covering his heel that was dated 01/03/23. The clinical record was reviewed on 01/05/23 at 12:29 P.M. A Quarterly MDS assessment, dated 11/08/22, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, coronary artery disease, orthostatic hypotension, and transient visual loss. The resident was at risk for pressure ulcers and had two Stage 2 pressure ulcers. The resident required extensive assistance of one staff member for bed mobility, transfers, dressing, toileting, and personal hygiene. The Weekly Wound Assessment records from the EHR (Electronic Health Record) were provided by the DON on 01/06/23 at 2:25 P.M. The records indicated the resident had a facility acquired suspected DTI (Deep Tissue Injury) to both the left and right heels. The left heel wound was first identified on 10/19/22. Wound descriptions were as follows: - 10/19/22, initial assessment, Left lateral heel noted with fluid filled blister to site with skin intact. No measurements were documented on the assessment. (A paper document, titled Wound Assessments was provided by RN 2 on 01/09/23, and indicated the wound measured 4 cm x 2.5 cm) - 11/23/22, Area noted with light pink and patial pale moist appearance with scattered scaly surrounding skin, size 3 cm x 2.5 cm (no depth listed); 0 to 25% slough; 51 to 75% epithelial tissue. - 01/04/23, Area noted with scabbing intact to site, size 0.7 cm x 0.7 cm; 76 to 100% epithelial tissue. The right heel wound was first identified on 11/16/22. Wound descriptions were as follows: - 11/16/22, DTI noted to right heel. No measurements were documented on the assessment. (A paper document, titled Wound Assessments was provided by RN 2 on 01/09/23, and indicated the wound measured 2 cm x 1.8 cm) - 11/23/22, right heel noted with improvement, area noted with scattered scaly skin with small light pink moist appearance, size 2 cm x 2 cm x 0.1 cm; 26 to 50% epithelial tissue; 26 to 50% granulation tissue. - 01/04/23, area noted with scab intact to site, size; 1.3 cm x 0.6 cm. The complete Care Plan, including resolved Care Plans, were provided by the DON on 01/05/23 at 12:30 P.M., and included, but were not limited to, the following: - A Care Plan for a blister to the resident's left heel, with an initiated date of 09/07/22, and a resolved date of 11/04/22, indicated the resident had received antibiotic therapy for the wound with an initiated date of 09/12/22. - A Care Plan for being at risk for impaired skin integrity related to a history of open areas to his bilateral lower extremities, with an initiated date of 04/12/22, and a revised date of 06/24/22. The current interventions included: Diet as ordered, labs as ordered, and to observe the skin with daily care. No preventative treatments were initiated on the Care Plan prior to the development of the pressure ulcers to the resident's heels. During an interview on 01/09/23 at 11:00 A.M., RN 2 indicated the resident had a blister on his left heel that was a pressure injury blister that started on 09/07/22. It had healed then it reopened. When she identified a new wound she measured them, completed an initial wound assessment, and notified the physician, the family, and the DON. The current Pressure Prevention policy, with a revised date of 08/2022 was provided by the Chief Nursing Officer on 01/09/23 at 11:31 A.M. The policy indicated, .PURPOSE .To maintain good skin integrity and avoid development of pressure ulcers .Care plan interventions shall be implemented based on risk factors identified in the nursing assessment . The current Pressure/Stasis/Arterial/Diabetic Wounds policy, with a revised date of 09/01/22, was provided by the Administrator on 01/09/23 at 10:39 A.M. The policy indicated, .PURPOSE .To provide weekly documentation of wound measurements and condition .Complete event for each impaired area .Document description of wound .Length .Width .Depth .Re-assessment/measurement weekly . 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to prevent and follow appropriate treatment orders related to skin breakdown for 4 of 5 residents reviewed for pressure ulcers. This deficient practice resulted in Resident B acquiring and worsening (an increase of wound size) of a Stage 3 pressure ulcer. (Resident B, C, D, and E) Findings include: 1. During an observation on 04/07/22 at 3:49 P.M., LPN (Licensed Practical Nurse) 4 was at the treatment cart in the hallway obtaining supplies for Resident B's wound dressing change. She had a non-adherent pad outside of the package and two pieces of tape hanging off the medication cart with one of them having her initials and date on it. She applied a pair of gloves and removed alginate from its package and placed on the top of the non adherent pad. The supplies were then carried to the resident's room and placed on the over bed table. LPN 4 assisted CNA (Certified Nurse Aide) 5 to turn the resident away from her, her brief was removed, and LPN 4 cleansed the resident with a wet wipe. The LPN indicated the resident did not have a dressing on her wound and was unsure how long it had been off for but knows she had one on that morning. CNA 5 indicated the dressing had come off around noon when she had cleansed the resident before. The wound was approximately the size of a half dollar. The wound bed was white and the area around the wound was pink in color. There was no odor. The LPN applied the dressing to the wound and covered it with tape. The resident was supplied with a new brief and made comfortable on her right side. The clinical record for Resident B was reviewed on 04/07/22 at 3:21 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 01/03/22, indicated the resident was comatose. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required total staff assistance for all ADL (Activities of Daily Living) care. The resident was at risk for skin breakdown with no pressure ulcers at the time of the assessment. The complete care plan included, but were not limited to, at risk for skin breakdown and pressure ulcers related to incontinence and immobility with a start date of 1/11/22, interventions included the following: - Administer medications as ordered. Monitor and document for side effects and effectiveness, - Administer treatments as ordered and monitor for effectiveness, - Apply lotion/moisturizer to the skin. Do not massage over bony prominences and use mild cleansers for peri-care/washing, - Assess/record/monitor wound healing. Measure length, width and depth where possible. Assess and document status of the wound perimeter, wound bed and healing progress. Report improvements and declines to the MD, and - Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. An Initial Pressure Ulcer Assessment, dated 02/16/22, indicated the resident had a Stage 3 (full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle was not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) to the coccyx. The wound measured 0.5 cm (centimeters) X (by) 0.3 cm X 0.1 cm. There was a moderate amount of exudate (a mass of cells and fluid that has seeped out of blood vessels). The wound edges were macerated (become softened). A Physician Wound Assessment and Plan, dated 02/16/22, indicated the resident had a Stage 3 Pressure Ulcer to her coccyx that measured 0.5 cm X 0.3 cm X 0.1 cm. There was a moderate amount of exudate. The treatment order was to cleanse the wound with normal saline or sterile water, apply alginate to the wound bed and cover with a dry clean dressing, daily. The wound was in the area of a previous wound. A Physician Wound Assessment and Plan, dated 02/23/22, indicated the resident had a Stage 3 Pressure Ulcer to her coccyx that measured 0.9 cm X 0.5 cm X 0.1 cm. There was a moderate amount of exudate. The wound had declined. The treatment order was changed to twice a day. A Physician Wound Assessment and Plan, dated 03/02/22, indicated the resident had a Stage 3 Pressure Ulcer to her coccyx that measured 0.6 cm X 0.3 cm X 0.1 cm. There was a moderate amount of exudate. The wound was healing. The treatment stayed the same. The clinical record lacked a weekly wound assessment from 03/02/22 through 03/16/22. A Physician Wound Assessment and Plan, dated 03/16/22, indicated the resident had a Stage 3 Pressure Ulcer to her coccyx that measured 2.5 cm X 1.5 cm X 0.1 cm. There was a moderate amount of exudate. The wound had declined. The wound had a possible infection with odor and purulence (white, yellow, or brown fluid.) The treatment changed to cleanse the wound with normal saline or sterile water, apply alginate ag to the wound bed and cover with a clean dry dressing, twice a day. A Physician Wound Assessment and Plan, dated 03/23/22, indicated the resident had a Stage 3 Pressure Ulcer to her coccyx that measured 2.0 cm X 1.1 cm X 0.1 cm. There was a moderate amount of exudate. The wound was healing. The treatment had remained the same from 03/16/22. A Physician Wound Assessment and Plan, dated 03/30/22, indicated the resident had a Stage 3 Pressure Ulcer to her coccyx that measured 1.8 cm X 1.1 cm X 0.1 cm. There was a moderate amount of exudate. The wound was healing. The treatment had remained the same. A Physician Wound Assessment and Plan, dated 04/06/22, indicated the resident had a Stage 3 Pressure Ulcer to her coccyx that measured 2.5 cm X 1.5 cm X 0.1 cm. There was a moderate amount of exudate. The wound had declined. The treatment changed to cleanse the wound with normal saline or sterile water, apply alginate to the wound bed and cover with a clean dry dressing, twice a day. The clinical record for the March and April TAR/ETAR (Treatment Administration Record/Electronic Treatment Administration Record) lacked documentation the treatment had been completed twice a day for the following dates: - 03/01/22, - 03/02/22, - 03/03/22 on nightshift, - 03/04/22 on nightshift, - 03/05/22 on nightshift, - 03/06/22 through 03/09/22, - 03/10/22 on nightshift, - 03/11/22 on nightshift, - 03/12/22 on nightshift, - 03/13/22 on nightshift, - 03/14/22 on nightshift, - 03/15/22 on nightshift, - 03/22/22 on nightshift, - 03/24/22 on nightshift, - 03/25/22 on nightshift, - 03/26/22 on nightshift, - 03/29/22 on dayshift, and - 04/05/22 on dayshift. Skin assessments were completed weekly per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 04/07/22 at 3:59 P.M., CNA 5 indicated the resident was non-verbal. The resident had a chronic wound to her coccyx that heals and then reopens. There were no staffing concerns in the facility. The residents were turned and repositioned every 2 hours. During an interview on 04/07/22 at 12:58 P.M., LPN 6 indicated after administering medications or treatments the nurse would document on the EMAR/ETAR that it was completed. If there was a blank on the EMAR/ETAR she would assume it meant it wasn't done. During an interview on 04/07/22 at 12:30 P.M., the Interim DON indicated if an EMAR/ETAR was left blank it could mean that the nurse forgot to sign out the medication or treatment. The EMARS/ETARS should be signed out. 2. The clinical record for Resident C was reviewed on 04/07/22 at 11:05 A.M. A Quarterly MDS assessment, dated 03/04/22, indicated the resident was cognitively intact. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a Stage 4 (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcer on admission. The resident requires extensive staff assistance with bed mobility. An Initial Pressure Ulcer Assessment, dated 09/18/21, on admission, indicated the resident had a Stage 4 pressure ulcer that measured 3.5 cm X 4.0 cm X 8.0 cm with undermining at 9 o ' clock was 8.0 cm and 10 o ' clock was 7.5 cm. A Physician Wound Assessment and Plan, dated 02/09/22, indicated the resident had a Stage 4 Pressure Ulcer to her coccyx that measured 3.0 cm X 1.5 cm X 3.0 cm, undermining 6 to 12 o'clock at 6.0 cm. There was a large amount of exudate. The wound was stable. The treatment was to cleanse the wound with normal saline or sterile water, apply alginate ag to the wound bed, pack loosely, and cover with a clean dry dressing, three times a day. A Physician Wound Assessment and Plan, dated 02/16/22, indicated the resident had a Stage 4 Pressure Ulcer to her coccyx that measured 3.0 cm X 1.5 cm X 3.0 cm, undermining 6 to 12 o'clock at 6.0 cm. There was a large amount of exudate. The wound was stable. The treatment changed to implement negative pressure wound therapy every Monday, Wednesday, and Friday, continuous. A Physician Wound Assessment and Plan, dated 03/02/22, indicated the resident had a Stage 4 Pressure Ulcer to her coccyx that measured 2.5 cm X 1.5 cm X 3.0 cm, undermining 6 to 12 o'clock at 6.0 cm. There was a large amount of exudate. The wound was healing. The treatment remained the same. The wound was improving. A Physician Wound Assessment and Plan, dated 03/16/22, indicated the resident Stage 4 Pressure Ulcer to her coccyx that measured 2.5 cm X 1.5 cm X 3.0 cm, undermining 6 to 12 o'clock at 6.0 cm. There was a large amount of exudate. The wound was stable. The treatment remained the same. There clinical record lacked a wound assessment from 03/02/22 through 03/16/22. A Physician Wound Assessment and Plan, dated 03/23/22, indicated the resident had a Stage 4 Pressure Ulcer to her coccyx that measured 2.5 cm X 1.5 cm X 3.0 cm, undermining 6 to 12 o'clock at 6.0 cm. There was a large amount of exudate. The wound was stable. The treatment changed to dakins wet to dry daily. A Physician Wound Assessment and Plan, dated 04/06/22, indicated the resident had a Stage 4 Pressure Ulcer to her coccyx that measured 2.5 cm X 1.5 cm X 3.0 cm, undermining 6 to 12 o'clock at 6.5 cm. There was a large amount of exudate. The wound was stable. The treatment remained the same. The February 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] - 02/09/22 at 12:00 A.M., - 02/14/22 at 4:00 P.M., and - 02/18/22 at 12:00 A.M. The wound vac was placed on 02/21/22 upon arrival. An open-ended physician order, with a start date of 03/24/22, indicated, staff were to apply dakins solution to the coccyx wound topically twice a day. The March and April 2022 ETAR lacked the treatment had been completed for the following dates and times: - 03/25/22 on nightshift, - 03/30/22 on nightshift, - 03/31/22 on nightshift, - 04/01/22 on nightshift, - 04/02/22 on nightshift, - 04/04/22 on dayshift and nightshift, and - 04/05/22 on nightshift. An Administration Progress Note for Dakins Solution signed by a QMA (Qualified Medication Aide), dated 04/05/22 at 1:36 A.M., indicated the nurse was notified at 1:15 A.M. The nurse indicated she had just sat down and wasn't doing it. They could do it in the morning. 3. The clinical record for Resident D was reviewed on 04/07/22 at 3:13 P.M. An Admission MDS (Minimum Data Set) assessment, dated 03/03/22, indicated the resident was severely cognitively impaired. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a Stage 4 and 2 unstageable (presents as an ulcer in which depth of tissue damage was not able to be determined due to presence of nonviable tissue) pressure ulcers. a. A Physician Wound Assessment and Plan, dated 03/02/22, indicated the resident had an Unstageable Pressure Ulcer to the left hip that measured 1.6 cm X 1.1 cm. There was 100 % eschar. The treatment plan was for skin prep to the hip. A Physician Wound Assessment and Plan, dated 03/16/22, indicated the resident had an Unstageable Pressure Ulcer to the left hip that measured 1.6 cm X 1.1 cm. There was 100 % eschar. The wound was healing. The treatment remained the same. A Physician Wound Assessment and Plan, dated 04/06/22, indicated the resident had a Stage 3 Pressure Ulcer to the left hip that measured 1.0 cm X 0.7 cm X < (less than) 0.1. There was 100 % eschar. The wound was debrided and removed eschar. The treatment was for skin prep to the hip. The clinical record lacked a wound assessment from 03/02/22 through 03/16/22. The resident discharged to the hospital on 03/17/22 through 03/31/22. The March 2022 TAR lacked treatment was completed for the left hip from 03/01/22 through 03/09/22. The April 2022 ETAR lacked documentation the treatment was completed on 04/02/22 and 04/05/22. b. A Physician Wound Assessment and Plan, dated 03/02/22, indicated the resident had a Stage 4 Pressure Ulcer to the coccyx that measured 7.0 cm X 7.4 cm X 4.0 cm. There was a moderate amount of exudate with warmth and odor. The treatment order was for Dakin's wet to moist, pack loosely daily. A Physician Wound Assessment and Plan, dated 03/16/22, indicated the resident had a Stage 4 Pressure Ulcer to the coccyx that measured 6.5 cm X 8.0 cm X 4.0 cm. There was a moderate amount of exudate. The wound was stable. The treatment order remained the same. The clinical record lacked a wound assessment from 03/02/22 through 03/16/22. A Physician Wound Assessment and Plan, dated 04/06/22, indicated the resident had a Stage 4 Pressure Ulcer to the coccyx that measured 8.0 cm X 8.0 cm X 3.0 cm. There was a moderate amount of exudate. The wound was stable. The treatment order changed to implement negative pressure wound therapy every Monday, Wednesday, and Friday, continuous. The April 2022 ETAR lacked documentation the treatment was completed on 04/02/22 and 04/05/22. c. A Physician Wound Assessment and Plan, dated 03/02/22, indicated the resident had a Deep Tissue Injury to the left heel that measured 1.5 cm X 1.3 cm. The treatment order was to apply skin prep to the heel daily. A Physician Wound Assessment and Plan, dated 03/16/22, indicated the resident had a Deep Tissue Injury to the left heel that measured 1.5 cm X 1.0 cm. The wound was healing. The treatment order remained the same. The clinical record lacked a wound assessment from 03/02/22 through 03/16/22. A Physician Wound Assessment and Plan, dated 04/06/22, indicated the resident had a Deep Tissue Injury to the left heel that was healed. The April 2022 ETAR lacked documentation the treatment was completed on 04/02/22 and 04/05/22. 4. The clinical record for Resident E was reviewed on 04/07/22 at 3:32 P.M. A Quarterly MDS assessment, dated 01/03/22, indicated the resident was cognitively intact. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required total staff assistance with bed mobility, transfers, dressing, toilet use, and bathing. The resident had one Stage 3 pressure ulcer on admission. A Physician Wound Assessment and Plan, dated 02/02/22, indicated the resident had a Stage 3 Pressure ulcer to the right buttock that measured 4.0 cm X 15 cm X 0.1 cm. The wound was healing. There was a large amount of exudate. The treatment was to cleanse the wound with normal saline, apply alginate to the wound bed and cover with a dry clean dressing twice a day. A Physician Wound Assessment and Plan, dated 02/16/22, indicated the resident had a Stage 3 Pressure ulcer to the right buttock that measured 3.5 cm X 13.5 cm X 0.1 cm. The wound was healing. There was a large amount of exudate. The treatment order remained the same. The resident had been refusing care both repositioning and supplements. The resident had a cluster of 7 wounds in the measured area. A Physician Wound Assessment and Plan, dated 03/02/22, indicated the resident had a Stage 3 Pressure ulcer to the right buttock that measured 9.0 cm X 11 cm X 0.1 cm. The wound had declined. There was a large amount of exudate. The treatment order remained the same. The resident had been refusing care both repositioning and supplements. The resident had a cluster of 6 wounds in the measured area. A Physician Wound Assessment and Plan, dated 03/16/22, indicated the resident had a Stage 3 Pressure ulcer to the right buttock that measured 4.0 cm X 8.1 cm X 0.1 cm. The wound was healing. There was a large amount of exudate. The treatment order remained the same. The resident had been refusing care both repositioning and supplements. The resident had a cluster of 4 wounds in the measured area. The clinical record lacked a wound assessment from 03/02/22 through 03/16/22. A Physician Wound Assessment and Plan, dated 03/30/22, indicated the resident had a Stage 3 Pressure ulcer to the right buttock that measured 4.0 cm X 8.5 cm X 0.1 cm. The wound was stable. There was a large amount of exudate. The treatment order remained the same. The resident had been refusing care both repositioning and supplements. The resident had a cluster of 2 wounds in the measured area and to please get a culture and sensitivity. A Physician Wound Assessment and Plan, dated 03/30/22, indicated the resident had a Stage 3 Pressure ulcer to the right buttock that measured 4.0 cm X 8.5 cm X 0.1 cm. The wound was stable. There was a large amount of exudate with purulent drainage. The treatment order remained the same. The resident had been refusing care both repositioning and supplements. The resident had a cluster of 2 wounds in the measured area. Please get a culture and sensitivity and start [MEDICATION(S)] (an antibiotic medication) 300 mg (milligrams), by mouth, three times a day, for 10 days. The March 2022 TAR lacked the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The March and April 2022 ETAR indicated the order was completed once a day from 03/18/22 through 04/06/22. The wound culture was obtained on 04/05/22. The wound culture was positive growth for the following organisms: - E.Coli - Providencia Stuartii - Morganella Morganii - Staphylococcus Aureus - Enterococcus Faecalis - [CONDITION(S)] Pneumoniae - Proteus Mirabilis During an interview on 04/07/22 at 2:53 P.M., the ADON (Assistant Director of Nursing) indicated the wound assessments were completed at least weekly and monitored daily. The wound physician came to the facility weekly and assessed the wounds. If the physician had new orders, she would input the orders into the clinical record. The nurses working the floor should follow the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 04/08/22 at 3:14 P.M., RN 7 indicated the week between 03/02/22 and 03/16/22 the wound physician was out sick and someone else was in charge of completing the weekly wound measurements. If they were not documented on the weekly skin assessment sheets, then they were not completed. She had not completed them that week. The current facility policy titled, Pressure Ulcers, dated 10/2014, was provided by the Clinical Support Nurse on 04/08/22 at 2:19 P.M. The policy indicated, .Purpose: To prevent pressure ulcers and promote healing .To assure that residents with pressure ulcers will receive necessary care and treatment to promote healing, prevent new ulcers from developing and prevent infection .Ongoing measurements shall be obtained by a designated, qualified person . The current facility policy titled, Laboratory Orders/Result Reporting, revised 11/2016, was provided by the Administrator on 04/11/22 at 1:56 P.M. The policy indicated, .To ensure the laboratory tests ordered by the physician are drawn and results received by the facility and reported to the attending physician . This Federal Deficiency relates to Complaints IN 117 and IN 511. 3.1-40(a)(1) 3.1-40(a)(2)

Based on record review, interview, and observation, the facility failed to adequately provide [MEDICATION(S)] for 2 of 3 residents reviewed for pain. (Resident 1 and 189) Findings include: 1. The clinical record for Resident 1 was reviewed on [DATE] at 2:35 P.M. The MDS (Minimum Data Set) assessment, dated [DATE], indicated the resident was cognitively intact. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She required the assistance of one or two staff members for ADLs (Activities of Daily Living). The resident had frequent severe pain during the assessment, making it hard to sleep at night. The pain had limited her day-to-day activities. An undated incident report indicated the resident had fallen on [DATE] at 6:30 A.M. The brief description added on [DATE], indicated the resident had been ambulating, had gotten dizzy, and fell . The nurse's notes were provided by the DON (Director of Nursing) on [DATE] at 4:58 P.M. A note, dated [DATE] at 5:15 P.M., indicated the resident was being sent to the emergency room for respiratory difficulties and increased pain in her left leg. A social service progress note, dated [DATE], indicated the resident returned to the facility from the hospital on [DATE]. A hospital discharge note, dated [DATE], indicated the resident had a closed fracture of the left hip. [MEDICATION(S)] 250 mg (milligrams) twice a day with meals, and oxycodone 5 mg every four hours as needed had been ordered for pain. A nurse's note, dated [DATE] at 6:30 P.M., indicated the resident had been admitted under Hospice care. A Hospice physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . No other pain medication was to be given per Family Member 1's request. A nurse's note, dated [DATE] at 4:32 A.M., indicated the resident was alert, moaning, and asking, Why won't you make the pain stop? and stating It hurts so bad. Nurse and aide repositioned resident and sat with resident to provide comfort. A nurse's note, dated [DATE] at 4:56 A.M., indicated resident was restless but not crying out. A nurse's note, dated [DATE] at 9:00 A.M., indicated the resident's Family Member 2 called the facility after the Hospice nurse informed her of the resident's increase in leg pain, anxiety, and shortness of breath. Family Member 2 instructed the facility not to give the resident any medication for pain or anxiety. The resident was repositioned in bed for comfort. A nurse's note, dated [DATE] at 9:10 A.M., indicated Family Member 2 phoned and gave consent for the pain medication to be given. A social service progress note, dated [DATE], indicated the SSD (Social Service Director) phoned the ombudsman making her aware of the family's desire to limit the resident's medication. The ombudsman indicated since the resident was able to make her needs known and was not under guardianship, medication could not be withheld. The SSD informed the family, Hospice nurse and facility staff of this information. A nurse's note, dated [DATE] at 11:30 A.M., indicated the resident complained of severe pain in legs and hip. [MEDICATION(S)] 0.25 mg was given. A nurse's note, dated [DATE] at 11:35 A.M., indicated the resident had died . During an interview on [DATE] at 1:14 P.M., QMA (Qualified Medication Aide) 4 indicated the resident would moan, cry out, and complain of pain in her left leg. The resident would be repositioned, offered drinks, and snacks as options instead of medication. During an interview on [DATE] at 3:25 P.M., the SSD indicated the resident would cry out in pain prior to the SSD having called the ombudsman and getting clarification on resident's ability to control her own pain medication request. During an interview on [DATE] at 9:40 A.M., the Hospice nurse indicated POA (Power of Attorney) papers had been provided by Family Member 1. The Hospice Quality Director had been involved in the case because of family issues, to ensure Hospice were providing adequate support for the patient. The resident was forgetful at times but, was good at expressing her needs. The resident was in pain as evidence by, verbalizing pain and restlessness, however the family member didn't want her to have anything other than Tylenol. The current facility policy titled PAIN ASSESSMENT, dated ,d+[DATE], was provided by the DOM (Director of Marketing) on [DATE] at 1:54 P.M. The policy indicated, .To identify those residents who utilize routine medications for pain or who utilize frequent PRN (as needed) pain medications in an effort to ensure adequate pain control is achieved . 2. During an interview on [DATE] at 1:55 P.M., Resident 189's family member indicated the resident was admitted to the facility from the hospital on [DATE] and had not received any pain medication since admission. The resident had been taking pain medication twice a day prior to admission and the last dose of pain medication she received was the morning of [DATE] before she left the hospital. An observation, on [DATE] at 2:00 P.M., LPN 6 was talking to the resident's family member. LPN 6 indicated they were working on getting the resident her pain medication at that time. During an interview on [DATE] at 9:56 A.M., Resident 189 indicated her pain medication was administered that morning. She had chronic pain issues and was hurting prior to getting the pain medication. She went without pain medication until yesterday. The resident's clinical record was reviewed on [DATE] at 10:30 A.M. The resident's hospital discharge summary, dated [DATE], indicated the resident was readmitted to the hospital on [DATE] for shortness of breath a few days after a prior hospitalization . The resident had been treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] The resident's hospital discharge instructions, dated [DATE], included physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and included the following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] An undated physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and 9:00 P.M. The order was written on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. administration. The medication was administered as ordered starting with the next scheduled dose on [DATE] at 9:00 A.M. An undated physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . An undated physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 11:30 A.M., a nurse's note indicated the resident arrived at the facility in a private car accompanied by her family members. On [DATE] at 5:00 A.M., a nurse's note indicated the resident was resting in bed with no signs or symptoms of distress. They continued to wait for medications to be delivered from the pharmacy. The resident's clinical record lacked documentation of any alternative or non-pharmacological pain-relieving interventions or that the resident was routinely assessed for pain. During an interview on [DATE] at 9:53 A.M., LPN 2 indicated when a resident was admitted from the hospital, nursing staff were to verify their medication orders. If there was a narcotic medication ordered that needed to be administered, staff were to notify the NP (Nurse Practitioner) and the NP would contact the pharmacy. The NP would send an escript (electronic prescription) to the pharmacy, the pharmacy would call the facility and give the nurse a code, and the nurse could remove the medication from the EDK (Emergency Drug Kit). Someone was available at the pharmacy on Saturdays until 2:00 P.M., but the facility could call the on-call pharmacy staff at any time. Medications should be available. During an interview on [DATE] at 1:31 P.M., the DON indicated if a medication was not available, they would contact the pharmacy. If the medication was in the EDK they would get it from there. If it was a new medication order and the facility faxed the order to the pharmacy before 5:00 P.M., the medication was supposed to be available with the evening medication delivery that same night. She was at the facility the day Resident 189 was admitted . She tried to get pain medication for the resident, she offered to go get the medications herself from the pharmacy. The medications were finally delivered after she made several attempts to get them. 3.,d+[DATE](a)

Based on interview and record review, the facility failed to ensure a treatment was implemented upon admission for a stage 2 pressure ulcer and additional interventions for a resident with a worsening stage 2 pressure ulcer, which resulted in a stage 3 pressure ulcer for 1 of 3 residents reviewed for pressure ulcers. (Resident B) Findings include: The clinical record for Resident B was reviewed on 9/16/21 at 1:01 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission MDS (Minimum Data Set) assessment, dated 12/25/20, indicated the resident's cognition was severely impaired. The resident had a stage 2 pressure ulcer (partial thickness skin loss involving the epidermis, dermis, or both), and required the assistance of two physical staff members with bed mobility. The admission assessment, dated 12/18/20, indicated the resident had an area on or around the coccyx/left buttock with no measurements documented. The skin integrity care plan, dated 12/18/20, indicated staff were to maintain skin integrity and to monitor for skin breakdown, pressure reducing devices in place if applicable. To assist the resident with turning/repositioning and/or encourage the resident to turn and reposition approximately every 2 hours. The Braden Scale, dated 12/21/20, indicated the resident had slightly limited sensory perception, very moist, chairfast, very limited mobility, and a problem with friction/shearing. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The pressure ulcer assessment, dated 12/25/20, indicated the resident had a stage 2 pressure ulcer on the left buttock which measured 2.0 cm (centimeters) in length, 2.5 cm in width, and a depth of 0.1 cm. The area was dark pink/red with irregular wound edges with a scant amount of drainage. The pressure ulcer assessment, dated 12/30/20, indicated the resident had a stage 2 pressure ulcer to the right buttock which measured 1.8 cm in length, 2.0 cm in width, and a depth of 0.1 cm. The wound bed was pink, the edges irregular with a scant amount of drainage. The clinical record indicated the resident's treatment to the right buttock was not initiated until 1/3/21. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The pressure ulcer assessment, dated 1/1/21, indicated the resident's wounds had the following measurements: -stage 2, left buttock measured 2.4 cm in length, 2.6 cm in width, and a depth of 0.1 cm -stage 2, right buttock measured 1.9 cm in length, 2.0 cm in width, and a depth of 0.1 cm The pressure ulcer assessment, dated 1/8/21, indicated the resident's right buttock area had combined with the left buttock/coccyx area. The pressure ulcer assessment, dated 1/8/21, indicated the resident had a stage 3 pressure ulcer (full thickness skin loss potentially extending into the subcutaneous tissue layer), which measured 7 cm in length, 7.5 cm in width, and a depth of 0.2 cm. The wound edges were irregular and the wound bed had an area of 2 cm x 2.5 cm of yellow slough with a moderate amount of drainage. The pressure ulcer assessment, dated 1/15/21, indicated the resident had a stage 3 pressure ulcer which measured 8 cm in length, 8.3 cm in width, and a depth of 3 cm. The wound edges were irregular and the wound bed had a area of 4 cm x 4 cm of yellow stringy slough with a moderate amount of drainage. The clinical record for the resident lacked documentation of any other implemented interventions after 1/1/21 or refusal of care. During an interview on 9/17/21 at 1:15 p.m., the Executive Director indicated the resident's wound declined rapidly, they implemented a wedge cushion to keep him off his back, he had a poor appetite, and refused care. On 9/17/21 at 1:54 p.m., the Executive Director provided a current copy of the document titled Pressure Ulcers dated 10/2014. It included, but was not limited to, Purpose .To assure that residents with pressure ulcers will receive necessary care and treatment .prevent new ulcers .Procedures .Treatment orders will be obtained .Interventions to prevent further pressure ulcer formation shall be initiated This Federal tag relates to Complaint IN 106 3.1-40(a)(2)